There were significant changes to the E/M services section of the CPT 2023 code set. These changes include revisions to the consultation services guidelines along with the deletion and/or revision of several codes. It is important to understand how to report consultation services correctly, as they are utilized in numerous care settings, including:
DEFINITION: AMA CPT 2023 Professional Edition, page 18 states, “A consultation is a type of E/M service provided at the request of another physician, other qualified health care professional (QHP), or appropriate source to either recommend care for a specific condition or problem.”
Consultations are complex services provided to the patient who is unknown to the consulting physician. As such, they require additional time to prepare a written report to communicate back to the treating physician. In addition, there may also be variations in payer policies when using consultation codes and it is recommended that third-party payers are contacted to understand their requirements for reporting these services.
REVISIONS: In 2023, the guidelines for consultation services were revised to include “Other qualified health care professional (QHP)” as they, in addition to physicians, may initiate diagnostic and/or therapeutic services at the same or subsequent visits. Instructions for Use of the CPT Codebook defines a “Physician or other qualified health care professional” as an individual who is qualified by education, training, licensure/regulation (when applicable) and facility privileging (when applicable) who performs a professional service within his or her scope of practice and independently reports that professional service. These professionals are distinct from “clinical staff”. A clinical staff member is a person who works under the supervision of a physician or other qualified health care professional, and allowed by law, regulation and facility policy to perform or assist in the performance of a specific professional service but does not individually report that professional service.
The revision of consultation codes does not require specific elements of history or physical examination. Documentation only needs to support a medically appropriate history and physical exam for the patient’s medical condition and situation.
Significant revisions have been made to the inpatient consultation codes. As of 2023, “Inpatient Consultations” has been revised to “Inpatient or Observation Consultations”. This better describes the services provided and is consistent with the revisions to other sections of inpatient and observation hospital E/M services. The guidelines have been revised to include observation patient services, as well as instructional guidance for reporting services in other facility settings.
DELETIONS: The ”Transfer of Care” guideline was deleted as it was determined that it was not needed. Services that constitute a transfer of care, such as those provided for the management of the patient’s entire care or care of a specific condition, are reported with the appropriate new or established patient E/M codes for office/outpatient visit, home, residence services, initial hospital inpatient/observation care or initial nursing facility care subsections.
Consultation codes 99241 and 99251 have been deleted. These two codes had a straightforward medical decision making. The descriptions of 99242-99245 and 99252-99255 have been changed to reflect the extra work involved in a consultation. As of 2023, 99242 and 99252 have straightforward medical decision making.
TIME: As with other subsections of E/M services, leveling is determined by medical decision making or time. There have been considerable changes in the time thresholds for consultation codes. Total time is used for leveling. Time is calculated based on the total amount of time spent on the date of the encounter instead of “typical” times that were utilized previously.
LEVELING: Outpatient Consultation for New or Established Patient
Inpatient or Observation Consultation for New or Established Patient
PLACE OF SERVICE: A consultation may be performed in different care settings, but must include the following components:
SELF-REFERRAL: Consultations initiated by the patient and/or patient’s family member are not reported with consultation codes. These would be reported with the appropriate E/M services codes, for example initial hospital/observation codes.
SUBSEQUENT CONSULTATION: Subsequent consultation services provided after a consultation is re-provided, in the outpatient setting is reported as an established patient (99212-99215 in the office or 99347-99350 for home or residence). For hospital/observation/nursing facility, a subsequent care code would be used (99231-99233 in the hospital or 99307-99310 for nursing facility).
HOSPITAL CONSULTATION: When a patient is admitted as an inpatient and a consultation is requested, the consultant should report the initial hospital inpatient or observation code instead of a consultation code.
E/M CPT codes 99252-99255 (Inpatient/Observation Consultation) may only be reported once by the consultant per admission.
Anne Mettler-Huebner, MT(ASCP), CCS, CCS-P, CPC, CPC-I
Auditor | Excite Health Partners
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