Consultation Codes

CPT codes for consultations are not covered, as they are considered provider-liable services regardless of the place of service (POS). The denial reason will instruct the provider to resubmit with the most appropriate Evaluation and Management (E/M) code.

Services in the Office or as an Outpatient 

These services should be submitted using either the new or established patient visit criteria according to the CPT definition.

Services in the Emergency Room

When a service takes place in the emergency room, the service may be submitted with an appropriate E/M code, using the appropriate POS code for an emergency room (ER) visit or an outpatient visit. Documentation must support the CPT code definition.  

Inpatient Stay

The first time a physician sees a patient in consultation, an initial hospital care code may be billed regardless of when the visit occurs during the inpatient stay. There may be multiple initial hospital care codes on the admit date or other dates, depending on the physician(s) who assesses the patient in consult. However, there should never be more than one initial hospital care code per physician. Please bill subsequent visits to the patient using subsequent care hospital visit codes.   

When a second physician sees a patient as an initial consult and all other required components are performed and documented, an initial hospital care code may be used. If the criteria for an initial hospital care code is not met and the documentation and criteria support a subsequent hospital care code, those codes should be used even if an initial care code has not been submitted by that physician. Rarely would code 99499 (unlisted E/M service) be used if documentation does not meet criteria for subsequent care. Documentation must establish that a medically necessary service was rendered and where the service took place.  

Services in a Nursing Facility 

The first time a physician sees a nursing facility patient in consult, an initial nursing facility care code should be billed if he or she is the admitting physician, regardless of when the visit occurs during the nursing facility stay. Other providers seeing the patient should be billed as subsequent care E/M codes.    

When a second physician sees a patient as an initial visit and all the required components are performed and documented, a subsequent nursing facility care code should be used, even if an initial code has not been submitted by that physician.