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Last Modified: 4/28/2019 Location: FL, PR, USVI Business: Part A, Part B

‘Consultation -- reported as …’ FAQ

Q: When should I use the “Consultation reported as” options in the Determining Level of E/M Services section of the E/M interactive worksheet?
A: Effective January 1, 2010, providers must report each evaluation and management (E/M) service, including those that would formerly have been reported as consultations, with an E/M code that identifies both the location of the patient’s visit and the complexity of the service performed and documented. However, although the Centers for Medicare & Medicaid Services (CMS) has eliminated the use of Current Procedural Terminology (CPT) consultation codes for payment of E/M services furnished to Medicare fee-for-service patients, evaluation and management services continue to be covered when medically reasonable and necessary.
Since consultation codes are no longer accepted for Medicare services, providers should select the E/M code that most accurately describes not only the place of service but also the level of service performed during the patient’s visit. According to CR 6740 external pdf file, any physician or qualified nurse practitioner who performs an initial evaluation in the inpatient hospital setting or nursing facility setting may bill an initial hospital care visit code (CPT codes 99221-99223) or initial nursing facility care visit code (CPT codes 99304-99306) appropriate to the location and level of service provided. However, if the service provided does not meet the criteria for the lowest level of service for initial hospital care or initial nursing facility care, 99221 and 99304 respectively, the service should be billed using the subsequent hospital care code or subsequent nursing facility care code appropriate to the location and level of service provided.
In addition, if the consultation took place in the consultant’s office, he or she should bill using a new patient office visit code (CPT code 99201-99205) or an established patient office code (CPT code 99211-99215) appropriate to the level of service provided.
Note: For your convenience, the E/M interactive worksheet includes the following options in the Determining Level of E/M Services section for those situations in which a consultation code may have been used in the past:
Consultation -- Reported as Initial Hospital Care
Consultation -- Reported as Subsequent Hospital Care
Consultation -- Reported as Initial Nursing Facility Care
Consultation -- Reported as Subsequent Nursing Facility Care
The suggested E/M code will be automatically calculated based upon the category of visit selected in the Determining Level of E/M Services section, your entries in required sections of the worksheet, and your preferred set of E/M documentation guidelines.
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