Coding for surgical services can be a complex task due to the multitude of rules, guidelines, and exceptions that are subject to frequent changes. General surgical consultations play a crucial role in patient management. Incorrect coding of these consultative services can have severe financial consequences for providers. It is essential to accurately report consultations by selecting the appropriate type or level of service and providing supporting documentation. The CPT 2023 code set has undergone significant modifications, including revisions to the guidelines for consultation services and the removal or revision of various codes. As physicians focus on delivering high-quality care, they can rely on general surgery medical coding and billing services for the correct documentation and billing of inpatient and outpatient consultation services.
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Reporting Consultation Services in 2023
Consultations are one of the categories under the Evaluation and Management section (99202-99499).
CPT 2023 guidelines define consultations as ” a type of evaluation and management service provided at the request of another physician, other qualified health care professional, or appropriate source to recommend care for a specific condition or problem” .
CPT defines four types of consultations:
- office or other outpatient
- initial inpatient
- follow-up inpatient, and
- confirmatory (also called a second opinion)
Within each type, three or five levels of complexity exist, with a distinct billing code for each level. The level depends on three key components: (1) the extent of the patient history taken, (2) the thoroughness of the physical examination, and (3) the complexity of the consultant’s medical decision-making.
As consultations involve complex services provided by a consulting physician to a patient who is unfamiliar to them, these services demand extra time to prepare a written report, which serves as a means of communication with the treating physician. Furthermore, the use of consultation codes may be subject to variations in payer policies. It is advisable to contact third-party payers to gain a clear understanding of their specific requirements for reporting such services.
In 2023, the consultation services guidelines were updated to incorporate “Other qualified health care professional (QHP).” CPT describes a “physician or other qualified health care professional” as an individual who possesses the necessary qualifications in terms of education, training, licensure/regulation (where applicable), and facility privileging (when applicable), who performs a professional service within his or her scope of practice and independently reports that professional service.
The 2023 CPT guidelines further note:
- A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.
- A ” consultation” initiated by a patient and/or family is not reported using the consultation codes. These consultations would be reported with the appropriate E/M services codes, for example initial hospital/observation codes.
- The consultant’s opinion and any services that were ordered or performed must also be communicated by written report to the requesting physician, other qualified health care professional, or other appropriate source.
- If a consultation is mandated (eg, by a third-party payer) modifier 32 should also be reported.
- When a consultation is conducted again in the outpatient setting, subsequent consultation services should be reported using the established patient codes. This includes using codes 99212-99215 for office visits or 99347-99350 for home or residence consultations. In the case of hospital, observation, or nursing facility settings, subsequent care codes should be utilized (99231-99233 for hospital visits or 99307-99310 for nursing facility consultations.
The codes for inpatient and outpatient consultation services are:
99242-99245 Office or Other Outpatient Consultations
99252-99255 Inpatient or Observation Consultations
- As of 2023, ” Inpatient Consultations” is revised to ” Inpatient or Observation Consultations” .
- The descriptions of 99242-99245 and 99252-99255 have been changed to reflect the extra work involved in a consultation.
- Codes 99242-99245 are used for service in the office or other outpatient setting including home and the emergency department.
- Codes 99252-99255 are used in hospital inpatients, for observation level patients, for residents in a nursing facility and for patients in a partial hospital setting.
- CPT codes 99252-99255 (Inpatient/Observation Consultation) may only be reported once by the consultant per admission.
- The consult codes are not distinguished as new or established patients. As long as the criteria for a consultation are met, clinicians may utilize these codes even for patients they have previously treated.
- Consultations require a formal request from another healthcare professional or an appropriate source. Additionally, a written report is required, and both these components should be thoroughly documented in the consult note.
CPT states that when the conditions for a consultation are met, codes 99252-99255 may be reported by a consulting physician in the inpatient setting. These codes are not recognized by Medicare and many private insurance companies.
- Levels of E/M Service: The level of E/M service for codes 99242-99245 and 99252-99255 may be selected based on the following:
- The level of the medical decision making (MDM) as defined for each service
- The total time for E/M services performed on the date of the encounter.
The time thresholds for consultation codes have undergone significant changes. 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. Total time is used for leveling:
Outpatient consultation for new or established patient
99242 – 20 Minutes must be met or exceeded OR Straightforward MDM
99243 – 30 Minutes must be met or exceeded OR Low MDM
99244 – 40 Minutes must be met or exceeded OR Moderate MDM
99245 – 55 Minutes must be met or exceeded OR High MDM
Inpatient or Observation Consultation for New or Established Patient
99252 -35 Minutes must be met or exceeded OR Straightforward MDM
99253 -45 Minutes must be met or exceeded OR Low MDM
99254 -60 Minutes must be met or exceeded OR Moderate MDM
99255 -80 Minutes must be met or exceeded OR High MDM
- Place of Service
- A specific request made by the physician, other QHP, or appropriate source. The CPT guidelines do not state who may document the request in the patient’s medical record.
- The consulting physician in turn communicates in a written report the findings of the consultation, opinion and any other services ordered/performed to the requesting physician, other QHP or appropriate source.
- A physician or other QHP consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.
- If the documentation does not identify a request for a consultation by the physician/QHP/other appropriate source and a written report on the consultation findings and recommendations back to the treating physician/QHP/other appropriate source, then the requirements for the consultation are not met.
The place of service and service type are defined by the location where the face-to-face encounter with the patient and/or family/caregiver occurs. Consultations performed in different care settings should include the following components:
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.
- In 2023, CPT codes 99241 and 99251 were deleted to align the medical decision making (MDM) levels with the levels that were defined in 2021 for the office outpatient codes and the 2023 hospital changes.
- All language regarding ” transfer of care” has been removed.
With significant changes to reporting consultation services in 2023, physicians can consider partnering with a general surgery medical billing company to ensure correct coding and claim submission.
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