Documentation for Office Consults

Steve Adams, MCS, CPC, CPC-H, CPC-I

CMS no longer allows reimbursement for the consultation codes, so these issues pertain specifically to commercial patients.

CPT defines a “consultation” as:

A type of evaluation and management service provided by a physician 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.[1]

A consultation is not the same as a transfer of care:

A “transfer of care” is the process whereby a physician who is providing management for some or all of a patient’s problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services.[2]

The AMA gives us the definition of a consult in that your opinion or advice is requested by another physician or other appropriate source. Other appropriate source would be another medical provider like MD/DO/PA/NP/CNM – not from a patient or a patient’s family member.

The decision to bill as an office “consultation” or “transfer of care” is dependent upon whether or not the other provider is seeking your “opinion or advice” or is simply “transferring the patient’s care” to you for management.

If you are going to bill an encounter as an office consult because the requesting provider wants your opinion and/or advice, reference in the note that the request came from the other provider. Mention the provider by name and offer your opinion and advice within the body of the patient’s note.

A proper chief complaint would look something like this – Patient is being seen today in consultation at the request of Dr. Jones for uncontrollable HTN. In the Assessment/Plan consider using Opinion/Advice.

Don’t forget, you are also required to communicate your opinion and advice back to the requesting provider. A letter outlining your opinion and advice must be sent back to the requesting provider unless you share a common note.
If you do not bill one of the outpatient consultation codes (99241-99245) because the requesting provider is transferring the patient’s care to you for a specific problem or there is no request for your opinion and/or advice, use the standard outpatient EM codes 99201-99215 based on if the patient is new or established and also on your documentation.

[1] 2013 CPT Professional Edition – AMA

[2] 2013 CPT Professional Edition – AMA



Comments are closed.