The requesting professional must be a physician or other qualified healthcare provider (e.g., nurse practitioner, physician assistant, resident acting under guidance of a teaching physician) currently involved in the patient’s care. Do not report consultation codes when a patient, family member, or third party requests a second opinion. Instead, select the most appropriate subsequent hospital care code (99231-99233).
The request must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting provider and the consulting physician; however, when this occurs, the verbal conversation must be documented by both the consultant (in the progress note) and the requesting provider (in the plan of care or as a written order). Standing orders for consultation are prohibited. Clearly document the reason for the service: the patient’s condition, sign, or symptoms that prompted the consult request, ensuring the medical necessity of the service.
Try to avoid terminology, such as “Consult hospitalist for perioperative management.” This leads to the payer’s confusion about co-management issues. The documentation should reflect the true intent of the service: “Consult hospitalist for perioperative risk assessment.” If necessary, ask the requesting provider to clarify the request. The consultant should further explain the request in his/her own note.
Report: After the patient’s assessment, the consultant documents the service and prepares a written report for the requesting provider, which includes the written request, consultation evaluation, findings, and recommendations.
It is appropriate for the consultant to initiate diagnostic services and treatment at the initial consultation service or at a subsequent visit, yet still qualify as a consult. In the inpatient setting, it is acceptable for the consultant’s report to appear as an entry in the shared medical record without need to forward a separate document to the requesting provider.
Code Use
Inpatient consultation codes are reported once per hospitalization. If reported more frequently, all claims within the same hospitalization subsequently reported with codes 99251-99255 are denied. This happens even when the consultant signs off and is re-consulted for a different problem during the same hospitalization.
A physician who provides patient services after the initial consultation reports subsequent hospital care codes 99231-99233 for each date in which a face-to-face encounter occurs.
A physician or qualified nonphysician provider may request a consultation from a member of the same group practice as long as the consultant possesses a legitimate expertise in a specific medical area beyond the requesting professional’s knowledge (e.g., a hospitalist may consult a member of his group who specializes in infectious disease).
This situation is likely to produce a rejected consult claim. In appealing the claim, submit notes from each member of the group (i.e., the requesting provider and the consultant) to demonstrate medical necessity and distinguish the expertise involved in each service. Medicare and payers who follow Medicare guidelines should reimburse the consult after the documentation is reviewed.
Co-management
Preoperative consults: Preoperative consultations are permitted when performed by any physician or qualified nonphysician provider at the request of a surgeon—as long as all requirements for performing and reporting the consultation codes are met. The service must be medically necessary and not provided for routine screening (i.e., consults for healthy patients scheduled for elective surgery).
Postoperative management: If a physician or qualified nonphysician provider who has performed a preoperative consultation is subsequently consulted and/or assumes responsibility for the complete or partial management of the patient’s condition(s) during the postoperative period, the appropriate subsequent hospital care code 99231-99233 is used.
Additionally, do not report consultation codes when the surgeon asks the hospitalist to take responsibility for the management of an aspect of the patient’s condition during the postoperative period (i.e., consult for postoperative management). In this situation, the surgeon is not asking the consultant for an opinion or advice for the surgeon’s use in treating the patient, and the surgeon is not expected to continue on the case. This constitutes concurrent care and is billed with the appropriate subsequent hospital care codes.