Does Medicare Accept CPT Consultation Codes?

Medical consultations involve a healthcare professional seeking the expert opinion or advice of another physician regarding a patient’s diagnosis or treatment. The Current Procedural Terminology (CPT) codes traditionally used for these services are 99241-99245 for office or other outpatient settings and 99251-99255 for inpatient settings. These codes differentiate a consultative service from a routine patient visit. Understanding the appropriate use and acceptance of these codes helps healthcare providers ensure accurate billing and compliance with payer policies.

Medicare’s Policy on Consultation Codes

Medicare Part B no longer recognizes or reimburses for CPT consultation codes (99241-99245 and 99251-99255). This policy change became effective on January 1, 2010. If these codes are submitted on a Medicare claim form, such as a CMS-1500, the claim will be denied.

The Centers for Medicare & Medicaid Services (CMS) eliminated separate payment for consultation codes to simplify evaluation and management (E/M) coding and reduce administrative burdens. CMS indicated the previous system led to confusion and a lack of clarity. While the concept of a consultation service remains clinically relevant, Medicare’s billing rules require these services to be reported using alternative E/M codes that describe the visit’s location and complexity.

Providers cannot use CPT consultation codes when billing Medicare beneficiaries for consultation-like services. Even though the clinical service aligns with a consultation, the billing mechanism must adhere to Medicare’s specific E/M coding requirements. Other payers may still accept consultation codes, but many follow Medicare’s lead, making it necessary for providers to verify each payer’s specific policies.

Appropriate Evaluation and Management Coding for Consultation-Like Services

For services that meet the clinical definition of a consultation but are provided to Medicare beneficiaries, healthcare providers must use standard Evaluation and Management (E/M) codes. The selection of the appropriate E/M code depends on the setting and the patient’s status. This approach ensures that the complexity and nature of the service are accurately reflected for billing purposes, even without using specific consultation codes.

In office or other outpatient settings, services traditionally billed as consultations should be reported using new patient (99202-99205) or established patient (99212-99215) E/M codes. A patient is “new” if they have not received professional services from the physician or another physician of the same specialty and subspecialty within the same group practice within the preceding three years. An “established” patient has received such services within that timeframe.

For services performed in inpatient settings, providers should utilize initial hospital care codes (99221-99223) or subsequent hospital care codes (99231-99233). If documentation does not fully support the lowest level initial hospital care code (99221), CMS guidance allows for the use of a subsequent hospital care code (e.g., 99231) to report the initial service, provided medical necessity and work requirements are met. The E/M service level for these codes is determined by the complexity of medical decision-making or the total time spent by the physician on the date of the encounter.

Documentation Guidelines for Consultation-Like Services

Even though specific CPT consultation codes are not used for Medicare billing, the medical record documentation must support the E/M code selected for consultation-like services. Comprehensive documentation demonstrates the medical necessity of the service and justifies the E/M code reported. This includes specific details about the interaction and clinical work.

Documentation should indicate a request for an opinion or advice was made by another physician or appropriate source regarding the patient’s condition. It should record the findings, the consulting physician’s diagnosis, and the recommended course of treatment. Documenting that a written report of these findings and recommendations was communicated back to the requesting physician aligns with the clinical definition of a consultation and supports the service provided.

The medical record must contain sufficient information to support the chosen E/M code level, whether based on medical decision-making or total time. This includes details about the complexity of the patient’s problem, the data reviewed and analyzed, and the overall risk associated with patient management. Documentation should reflect the depth of history taken, the extent of the examination performed, and the thought process behind medical decisions made.