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Deborah Grider, CPC, CPC-P, CPC-I, COC, CPMA, CEMC, CCS-P, CDIP
Many practitioners have stopped billing consultations. Why is that? Even though consultation codes 99241-99245 (outpatient) and 99251-99255 (inpatient) are no longer reported or payable by Medicare, other payers still allow us to report consultations, including many Medicaid state agencies. Medicare stopped allowing consultation codes on January 1, 2010.1 But United Healthcare has a new payment policy that allows payment for consultations.2 Other payers, including Cigna, Aetna, and Anthem, do cover consultations in most states. However, many Medicare Advantage Plans follow Medicare guidelines, so it is advisable to check with each payer before reporting consultations and to keep a list of which payers accept consultation codes.
So what is truly a consultation? The Current Procedural Terminology (CPT) instructional notes state: “A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem.”3
What is an appropriate source? According to the American Medical Association, appropriate sources for a consultation request includes physicians, physician assistants, nurse practitioners, psychologists, social workers, lawyers, or insurance companies.4
The inpatient consultation codes (99251-99255) apply to consultations performed in the hospital, partial hospital, or nursing facility settings. The outpatient consultation codes (99241-99245) are reported in the office, domiciliary, rest home, or home settings.
For an inpatient consultations (99251-99255), the following requirements must be met: