Q&A: Reporting outpatient consultations

Q: How are outpatient consultations reported? And what qualifies as a consultation?

A: Outpatient consultations are reported with CPT codes 99242-99245. Each has a time and a level of medical decision-making (MDM). You report either the time or MDM. Here's an overview:

• 99242: 20 minutes or straightforward MDM
• 99243: 30 minutes or low MDM
• 99244: 40 minutes or moderate MDM
• 99245: 55 minutes or high MDM

So, what is the consultation? In a consultation, provider A asks provider B (the consultant) to recommend care for a patient's specific condition or problem. For example, often a general practitioner will be faced with something and will say, “I don't know how to do it, let me ask a specialist.”

These consultation codes are reported by provider B (the consultant), not the requesting provider. And the consultant's opinion and any services that were ordered or performed must be communicated back to the requesting provider by written report. So, it's circular: You have provider A talk to provider B, and then provider B sends information back to provider A.

These services can be provided face-to-face with the patient or by using telemedicine services, if appropriate. If you look at these codes in your CPT book, note there's a star in front of them. The star means the code can be reported when the patient is seen face-to-face or using telemedicine audio visual services.

These outpatient consultation codes can be used for patients in an office or other outpatient site, home or residence, and emergency department. There are no separate codes for new and established patients or initial and subsequent services.

One thing that is a little bit different from other codes: These services can be provided by physicians, qualified healthcare professionals, or other appropriate sources. That includes non-clinical social workers, educators, lawyers, or insurance companies.

Outpatient consultations are reported for initial consultations only. Only one consultation may be reported by consultants per patient admission/encounter.

The consultant may initiate diagnostic therapeutic services during this visit and those can be reported separately.

If a consultation is mandated, meaning required by a third-party payer or other source, use modifier -32 (Mandated services).

Do not report a consultation code if the encounter was initiated by the patient and/or family. Sometimes a patient or their parent or guardian will say, “I want a consultation with you about the patient.” That's not a consultation. A consultation is initiated by a provider.

Editor’s note: This article originally appeared in JustCoding. This information was provided by Terry Tropin, MSHAI, RHIA, CCS-P, during HCPro’s webinar, “CPT Coding for Outpatient Services: Office Visits, Emergency Department Visits, and Consultations.”