Why Reporting Consultation Services Can Be Tricky

The AMA updated consultation services for 2023.

EDITOR’S NOTE: The American Medical Association (AMA) announced major revisions to Evaluation and Management (E&M) Services for Jan 1, 2023. The E&M categories that will undergo revision in 2023 include inpatient and observation care services, emergency department services, consultations, nursing facility services, home and residence services, and prolonged services.

Revisions to the E&M category for consultations include updates within two subcategories — office or other outpatient consultations and inpatient consultations with both subcategories currently divided into five levels of service.

As defined in the American Medical Association’s CPT® codebook, a consultation is a type of E&M 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. 

The biggest revision to the consultation E&M category, as with all the categories undergoing revision for 2023, is that the three key components, history, exam, and medical decision making are no longer required for reporting these services.

A medical appropriate history or physical as determined by the physician or APP should be documented; the level of service is determined solely be the level of medical decision making or time. The AMA redefined what “time” includes for selection of the level of service, time is now the total time on the date of the encounter and includes both face-to-face time and non-face-to-face time.

For both subcategories, a level one E&M, 99241 for office or outpatient services and 99251 for inpatient or observation consultation has been deleted. Additionally, similar to the combining of inpatient and observation care services into one E&M category, the inpatient consultation subcategory title has been revised to include consultations performed on observation patients.

Consultations can be tricky to report accurately, this is where expert understanding of the consultation guidelines within the CPT codebook is needed. A few things to consider with the 2023 guidelines:

1. A physician or other qualified health care professional consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.
2. A “consultation” initiated by a patient and/or family member is not a consultation and is not reported using the consultation codes.
3. The consultation’s opinion and any services that were ordered or performed must be communicated by written report to the requesting physician, other qualified health care professional, or appropriate source.
4. Within the office/outpatient guidelines:
   • The outpatient consultation codes should be used to report consultations in the office or other outpatient site, including the home or emergency department.
     
   • Follow-up visits in the consultant’s office or other outpatient facility that are initiated by the consultant or patient are reported using the appropriate codes for established patients in the office or home or residence.
   • Services that constitute transfer of care are reported with the appropriate new or established patient codes for office or other outpatient visits or home or residence services.
5. Within the inpatient or observation guidelines:
   • Codes 99252, 99253, 99254, 99255 are used to report physician or other qualified health care professional consultations provided to hospital inpatients, observation-level patients, residents of nursing facilities, or patients in a partial hospital setting, and when the patient has not received any face-to-face services from the physician or other qualified health care professional or another physician or other qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice during the stay.
   • Subsequent consultation services during the same admission are reported using subsequent inpatient or observation hospital care codes or subsequent nursing facility care codes.

As many of you know, on Dec. 14, 2009, the Centers for Medicare & Medicaid Services (CMS) released policy stating that consultation codes would no longer be accepted for Medicare Part B payment beginning with calendar year 2010.  Since then, we have seen many commercial payers align with CMS and no longer recognize or reimburse for consultation codes.  

Healthcare organizations and physician practices address the coding of consultation services in different ways.  A consultation is a recognized services of the AMA and an E&M category within the CPT codebook therefore, I maintain the opinion that as coding professionals we should instruct physicians and advanced practice providers (APP) to be agnostic to payer policy and code consultation services with the consultation E&M codes.  Coding and revenue cycle professionals can then play an important role in supporting our physicians and APPs and edit the codes when appropriate for claim submission based on payer policy. 

Perhaps this is a good time to review the workflow for consultation services within your organization or practice. I have a checklist for overall readiness that I recommend organizations consider so they are well-prepared for January 1, 2023:

1. Identify a subject matter expert that fully understands the revisions
2. Determine who needs to be educated and when
3. Review documentation practices and how time is currently captured and documented, identify documentation not needed for patient care.
4. Review coding and charge capture workflows; if these functions are outsourced, ask your coding vendor how they are preparing for the code changes.  As your EMR and HIS vendors their readiness plans.
5. Consider dual coding of sample E&M services in 4th quarter of 2022
6. Continue/start to capture complete diagnoses for patient acuity
7. Educate physicians and coders on the importance of documenting and coding the social determinants of health
8. Share your readiness plan with your compliance department
9. Work with commercial payors for transparency
10. Communicate, communicate, communicate

More to come next week when I share the revisions to nursing facility services.

Programming note: Listen to Colleen Deighan’s live reporting on E&M updates today during Talk Ten Tuesdays with Chuck Buck and Dr. Erica Remer at 10 Eastern.

 References:

American Medical Association 2023 E&M Code and Guideline changes, available at: 2023 CPT E&M descriptors and guidelines (ama-assn.org)

AMA CPT® Professional 2022 Codebook © 2021 American Medical Association

Revision to CMS consultation policy, available at: 6740 | CMS