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CPT Consultation Code Changes:
Effective January 1, 2006
(PYA Alert dated February 2, 2006)
The Follow-Up Inpatient Consultation codes (99261-99263) and the Confirmatory Consultation codes (99271-99275) have been deleted from CPT for 2006. Beginning January 1, 2006, medically necessary follow-up visits after an initial consultation service shall be reported using the appropriate subsequent visit/established patient E/M visit codes.
Consultation and Second Opinion Evaluation Coding Tool
Inpatient Hospital Setting |
An initial consultation or second opinion evaluation furnished to a patient in the inpatient setting will be reported with the following:
Note: Use an initial inpatient consultation code only once per episode of care. |
If the documentation meets requirements for consultation coding*, assign a code from the following Initial Inpatient Consultation codes:
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99251-99255 |
If the documentation does not meet consultation coding requirements*, assign a code from the following Subsequent Hospital Care codes:
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99231-99233 |
Follow-up visits to a consultation or second opinion evaluation furnished to a patient in the inpatient setting will be reported with the following:
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Assign a code from the following Subsequent Hospital Care codes:
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99231-99233 |
Nursing Facility |
An initial consultation or second opinion evaluation furnished to a patient in a nursing facility will be reported with the following:
Note: Use an initial inpatient consultation code only once per episode of care. |
If the documentation meets the requirements for consultation coding*, assign a code from the following Initial Inpatient Consultation codes:
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99251-99255 |
If the documentation does not meet the requirements for consultation coding*, assign a code from the following Subsequent Nursing Facility Care codes:
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99307-99310 |
Follow-up visits to a consultation or second opinion evaluation furnished to a patient in a nursing facility will be reported with the following:
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Assign a code from the following Subsequent Nursing Facility Care codes:
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99307-99310 |
Office or Other Outpatient Setting |
An initial consultation or second opinion evaluation furnished to a patient in the office or other outpatient settings will be reported with the following: |
If the documentation meets the requirements for consultation coding*, assign a code from the following Office or Other Outpatient Consultation codes:
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99241-99245 |
If the documentation does not meet the requirements for consultation coding*, assign a code from the following Office or Other Outpatient New or Established Patient codes:
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99202-99205 (new)
99212-99215 (est.) |
Follow-up visits to a consultation or second opinion evaluation furnished to a patient in the office or other outpatient settings will be reported with the following:
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Office or Other Outpatient Established Patient codes
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99212-99215 |
*General Consultation Coding Requirements:
Proper documentation of a reasonable and medically necessary consultation service should meet the following criteria as per the CMS Manual System, Pub 100-04 Medicare Claims Processing Transmittal 788 Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners 30.6.10 – Consultation Services (Codes 99241-99255):
- Request: “A request for a consultation, (the requestor and the reason for the consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record, (may be written on a physician order form in a shared medical record).”
- Report: “After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician. In an office setting, the consultation report is a separate document to the requesting physician or qualified NPP and readily available. In the inpatient setting, the consultation report may be part of a common medical record."
Please contact Maggie Mac if you are interested in learning more about Consultation Coding.
The information provided via PYA Alert, Tax Planning Alert, or Audit and Accounting Alert should not be construed as accounting, auditing, consulting, or legal advice on any specific facts or circumstances. The contents are intended for general information purposes only. Please contact us at (800) 270-9629 to discuss your specific situation or to discuss any specific questions you may have.
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