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To consult or not consult

Medical Economics JournalMarch 25, 2019 edition
Volume 96
Issue 6

What is-and isn't-considered a healthcare "consultation"? 


I am an internist with my own practice and am called on by specialists to evaluate patients for diabetes management and for pre-operative clearances.  Can I bill these services as consultations?  Also, can my nurse practitioner bill consultations for these services?

A: These are great questions, and we will need to delve into the definition of consultations in order to answer them.  

Who can provide a consult?

First, per Current Procedural Terminology (CPT) guidelines, consults may be requested by persons other than physicians (e.g., physician assistants, nurse practitioners, chiropractors, physical therapists, occupational therapists, speech-language pathologists, psychologists, social workers, lawyers or insurance company representatives). 

So yes, consults can be performed by a physician or other qualified non-physician practitioner (NPP) (e.g., nurse practitioner and physician assistant) if the service is within his or her scope of practice and licensure requirements in the state where he or she practices and the requirements for physician collaboration and physician supervision are met.

Consultation basics

Let’s look at the basic elements that are required for consultations. Medicare no longer reimburses for consultation; nevertheless, the guidelines were developed by the Centers for Medicare and Medicaid Services (CMS). Check with your local payers to see if they reimburse for consultations.

According to CPT, a consultation is an Evaluation and Management (E/M) 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.

Per CMS, the basic consultation elements include:

  • The consultation request,

  • The reason for the request,

  • The services rendered, and

  • The report from the consulting physician.

You can remember these as the four R’s: request, reason, render and report. Here are the steps to document these requirements:

1. The requesting physician should document the request for consultation in the patient record, including the specific reason for the consultation and how the consultant physician was contacted (e.g., phone, fax or letter). Likewise, the consultant physician should document that the consultation was requested, by whom and why.

2. The consultation services rendered should be documented following the Evaluation and Management (E/M) guidelines. Consultation codes require all three elements (i.e., history, exam, medical decision making) to be met in order to support a code level.  Time-based coding can also be utilized when more than 50% of the time is spent in counseling/coordination of care. 

3. The consultant physician should provide a written report of services provided, findings and recommendations or planned follow-up. When the requesting physician and consulting physician share a common patient record, this documentation can be included in the patient’s progress notes. Otherwise, a copy of the consultant’s written report should be included in the patient’s record.

If any of these requirements aren’t met, then the appropriate code should be billed based on place and type of service.  

When is a consultation not a consultation?

A consultation is not a transfer of care. A transfer of care occurs “when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition” (Medicare Claims Processing Manual, chapter 12, section 30.6.10.B).

For instance, if a patient who doesn’t have a medical home seeks care at an urgent care facility, the nurse practitioner at the facility might recommend that the patient contact a certain family physician to establish ongoing care. This is not a consultation because the nurse practitioner in the urgent care facility is not requesting advice or an opinion on managing the patient’s condition.  

The same reasoning applies when a patient is referred from an emergency department. A referring physician documents or intends a “referral and treat.” You know your referring physicians/NPP’s. If you know that the referring physician expects you to treat the patient’s condition, the visit is not a consultation.

These scenarios are transfers of care or referrals.

A consultation is not when a surgeon asks you to manage an aspect of the patient’s care in the post-op period. The surgeon is not asking for your opinion or advice, so this care is concurrent to the surgeon’s care.

A consultation is not  a request from a patient or family member. The fundamental requirements of a consultation is a provider or other source (listed above), so requests from a family member or patient should be reported using office visit, home service or domiciliary/rest home care codes, not consultation codes.

Consultations are not routine between physicians in the same group. Consultations can be requested of another physician in your group who has expertise in a specific medical area; however, these requests should be kept to a minimum.

A consultation is not a split/shared visit. The guidelines preclude a consultation being performed as a split/shared visit.

A consultation cannot be billed more than once per consultant per facility admission.

A consultation cannot be billed as a 99211. This is a minimal service and doesn’t meet consultation guidelines.

Pre-operative clearances

It’s not uncommon for a surgical specialist to request preoperative clearance from the patient’s family physician. As with other consultation services, the preoperative clearance consultation should involve a request for opinion or advice. For example, do the comorbid conditions of this patient require any special considerations? Can this patient safely undergo this procedure?

When you report a consultation for preoperative clearance, use the appropriate CPT code for the level of service and setting where the consultation services were rendered as well as diagnosis codes that indicate the necessity of the consultation. Also, code any diagnoses that arise during your consultation.

Medicare guidelines state that, following a preoperative consultation, if the consultant assumes responsibility for managing a portion of the patient’s condition(s) during the postoperative period the consultation codes should not be used. In this situation, you should use the appropriate subsequent hospital care codes to bill for the concurrent care in the hospital setting and use the appropriate established patient visit codes for services provided in the office.

Renee Dowling is a billing and coding consultant with VEI Consulting in Indianapolis, Ind. Send your billing and coding questions to medec@ubm.com.

Additional initial and subsequent consultations instructions

Here are some additional tips to keep in mind:

  • In an office or outpatient setting, if an additional request for a consultation regarding the same or a new problem with the same patient is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation codes may be used again.

  • For a second opinion evaluation (patient and/or family requested) in the facility setting arranged through the attending physician, the evaluation is reported as an Initial Inpatient Consultation service if the consultation requirements are met.

  • Medicare does not require a written report  to be sent to a physician or qualified NPP when a second opinion evaluation visit has been requested by the patient and/or family.

  • A written request for a consultation should be included in the requesting physician’s or qualified NPP’s plan of care, but the absence of a request should not be held against the consultant in a post-payment review.

  • A consultation request  may be written on a physician order form in a shared medical record.

  • The reason for the consultation service must be documented by the consultant in the patient’s medical record. 





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