There is a specific CPT code for each medical treatment and service. These codes are involved in the formulation of a medical bill, where codes are indicated in the bill along with service names and charges. Then the insurance payer recognizes these services based on CPT codes and pays for the insurance coverage of their patients, and the hospital gets the reimbursement. One of these codes is the CPT code for consultation.
These codes are used when a patient takes a consultation with a physician. But there have been recent updates in the consultation codes and its definition as well. Let’s have a look at the detailed guide about CPT code for consultation that will help you better understand how to use these codes in a hospital bill.
What Are CPT Codes?
In order to move to define CPT code for consultation, you must first know what are CPT codes, and and its categories.
CPT stands for Current Procedural Terminology codes. It distinguishes health services from each other so that it helps hospitals to charge their patients for each service individually. CPT codes were introduced by the American Medical Association (AMA), and are used by physician, non-physician practitioners, outpatient facilities, and laboratories.
These codes identify medical, surgical, and diagnostic health services that also include a CPT code for consultation. The special combination of letters and numbers specifies a certain health service. CPT codes are 5-digit codes, sometimes entirely numeric and sometimes alphanumeric.
Code Categories
CPT codes contain 3 types of code and are divided into categories.
Category 1: This category includes codes that are widely used by health practitioners. All category codes are approved by the Food and Drug Administration (FDA).
Category 2: Codes included in this category are supplementary. That means medical coding can be completed without using these codes in a bill. It helps define the quality of healthcare service.
Category 3: These are temporary codes assigned to those health services that are not used much by health practitioners. Category 3 is allocated to new and emerging health services. These codes may remain here for up to 5 years after which if it is widely used, are transferred to Category 1. If these codes are not used by health institutes, they are deleted from this category.
What Was The Old Definition Of Consultation?
The previous definition of consultation when it comes to CPT was when you request a physician and seek advice or opinion regarding a specific health issue. According to the CPT rules of 2007, consults may get requests from a person other than physicians. The list of these “other than physicians” continues:
- Assistants of physicians
- Nurse practitioners
- Chiropractors
- Physical and occupational therapists
- Speech and language pathologist
- Psychologist
- Social workers
- Lawyers
- Representatives from the insurance company
Additionally, consultation doesn’t signify the transfer of a health care service. Let’s suppose a case in which a patient who didn’t seek any healthcare service previously, was admitted to an emergency facility and is advised by a physician to continue treatment with a family physician to get a cure. In that case, this is not consultation because the physician is not requesting an opinion regarding the patient’s health.
Update Of CPT Code For Consultation
The Centers for Medicare and Medicaid Services (CMS) is a part of the Department of Health and Human Services (HHS). CMS helps health researchers find data. It also manages Medicare and multiple insurance programs.
When we talk about the CPT code for consultation, CMS stopped recognizing consult codes in 2010. However, outpatient (99241-99245) and inpatient (99251-99255) consultation codes were still active and being used by health practitioners. But these 2 codes are now discarded in 2023 since they were rare in medical coding. As described earlier, codes that are not much used by health practices are deleted from category 3.
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When CMS stopped recognizing CPT code for consultation, it did not state that it doesn’t understand the concept of consultation. Not recognizing a specific code means, CMS now uses a different code set for consultation services, i.e. for inpatient consultation services (99221-99223) is now used.
But you must remember that if your document requirements don’t involve the use of least-level hospital codes, you have to use a subsequent code CPT code for consultation (99231-99233).
For office use and outpatient consultation services (99202-99215) patient visit codes are used, but the code may vary depending on the patient, if it is new or an established one. Healthcare institutes are also required to use the above CPT code for consultation during patient observation processes as observation is also a part of outpatient services.
At last, the CPT code for consultation of the patients that were seen in the emergency department and discharged from the hospital, ED codes of (99218-99285) are used.
New Definition Of Consultation
As years passed, CMS observed the change in consultation services on the basis of which they canceled the previous definition of consultation. The new definition is pretty much the same as the previous one but does have a better understanding of what consultation is in terms of CPT.
A consultation is an observation and management service provided upon the request of another physician, or any qualified health professional or requested by an appropriate source to recommend the patient to get help for a specific health-related issue.
The physician or other professional consultant may conduct diagnostic and therapeutic services on the same visit or subsequent patient appearance.
Another important thing to note is that CPT prohibits the use of CPT code for consultation when it is initiated by any friend, family member, and other appropriate sources. They have made a clear list of “other appropriate sources” that include non-clinical social workers, educators, lawyers, and many others. They have also clearly stated that a patient is not required to pay for consultation services requested by the ones mentioned on the list.
What Is The Actual Documentation Of Consultation?
The definition and CPT code for consultation have been changed, but the documentation is still the same. These 4 things should be mentioned in the patient documents during consultation:
Consultation Request
The physician who requests a patient to take a consultation must mention his consultation request in the patient report.
Reason Of Request
Requesting physician should also state the reason for the consultation request in the patient reports, along with the method of contacting the consultant physician, this may be a phone or fax number and letter.
Similarly, the consultant physician will have to state in the patient report who requested the consultation and why.
Services Given
Rendered consultation services will have to be mentioned in the document according to the guidelines of E/M (Evaluation and Management) documentation of 1995 or 1997.
Besides, the document must also contain the details of the service provided by the consultant physician.
The Report Provided By The Consultant Physician
Requesting and consultant physicians work closely with the same patient, so they maintain the same type of patient record. The report can be included in the patient’s progress. But if only requesting physician has the access to patient documentation, a written copy of the consultant has to be included in the patient’s record.
Conclusion
The update of the CPT code for consultation had created a lot of confusion among health practitioners and medical coders as well. However, with the help of our guide, you will now be able to differentiate between the actual definition of the consultation along with new code updates.