When can you code for a consultation? According to the latest CMS guidance, Medicare won’t pay for a reasonable and medically necessary consultation unless you meet these three requirements:

• The service is provided by a physician or qualified nonphysician practitioner (NPP)¹ whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. This requirement distinguishes a consultation service from other E&M visits.
• The consultant documents both a request for a consultation from an appropriate source and the need for consultation (i.e., the reason for the service) in the patient’s medical record. This also must appear in the requesting physician’s or qualified NPP’s plan of care, which is in the patient’s medical record.
• The consultant provides a written report of his or her findings and recommendations, which shall be provided to the referring physician. If, say, a large multispecialty group practice uses a shared medical record, it would be enough to include the consultant’s report in the medical record documentation rather than requiring a separate letter from the consultant. Those findings and recommendations should be available in the consultation report.

What expertise is required? The intent of a consultation is that a referring professional is asking the consultant for help (e.g., an opinion or direction) in evaluating or treating a patient because that consultant has expertise in a specific medical area beyond the requesting professional’s knowledge.

Will you get paid for intraoffice consultations? Provided that the expertise requirement is met, Medicare will pay for a consultation even when the requesting professional and the consultant are both in the same group practice. However, a consultation service shall not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting.

When can care be initiated? A physician or qualified NPP may initiate diagnostic services and treatment at the initial consultation service.

Definitely Not a Consult

The following do not meet the criteria for consultation services: Standing orders in the medical record; no order for a consultation; and no written report of a consultation.

Transfer of care. When a physician or qualified NPP asks another physician or qualified NPP to take over responsibility for managing the patient’s complete care, it is considered a transfer of care. Coding should be for the appropriate level of new or established E&M code or Eye Code, but not a consultation code.

CMS provides this example. An ER physician treats a patient for a sprained ankle. The patient is discharged and told to visit the orthopedic clinic for follow-up. Since the ER physician doesn’t need any advice or opinion from the clinic’s physician, the clinic can’t report a consultation service but should report the appropriate office or other outpatient visit code instead.

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1 Medicare defines an NPP as “any nonphysician licensed medical professional.” It includes in this definition providers such as physician assistants, nurse practitioners and clinical nurse specialists, as well as social workers, physical therapists and speech therapists.

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For the latest coding updates, visit www.aao.org/aaoesite/coding.