What is consultation code and when to use.

type of service (CPT codes 99241-99275) provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services.

The request for a consultation from the attending physician or other appropriate source and the need for consultation must be documented in the patient's medical record. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated to the requesting physician or other appropriate source.

A consultation initiated by a patient and/or family, and not requested by a physician, is not reported using the initial consultation codes but may be reported using the codes for confirmatory consultation or office visits, as appropriate.

Any procedure that can be identified with a specific CPT code performed on or subsequent to the date of the initial consultation should be reported separately.

If a consultant subsequently assumes responsibility for management of a portion or all of the patient's condition(s), the consultation codes should not be used.

However Medicare and Medicare HMO does not accept consultation code in 2010. Please see the previous post related on consultation code update from Medicare.

Consultants and Inpatient Concurrent Care

A consultant may become a concurrent care provider on a case if his/her services after the consultation are necessitated by the condition of the patient, and meet the reasonableness test for standard of care. The consultant may bill for the initial consultation (if it meets the definition of a consultation described in the “Consultations” section of this manual), but not for additional consultations, as he/she cannot be both a consultant and a concurrent care provider on the same case.

Subsequent care after the initial consultation should be submitted as the appropriate level hospital inpatient service.

If, after consultation, the surgeon’s role is assumed by the consultant, the consultant may bill for neither additional consultations nor follow-up care, as the global surgery period policy (GSP) supersedes this policy.

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