CPT Code For Consultation (2023) | Description, Guidelines, Reimbursement, Modifiers & Example

CPT code(s) for consultation and other codes are maintained by the CPT editorial panel. Physicians who provide consultation services for the Part B segment can bill the consultation CPTs. The consultation note is like an E & M note. So, all three critical components of E & M, including history, examination, and medical decision-making, should be present for appropriate code selection. 

Coders should pay appropriate attention while assigning the consult code to an outpatient, inpatient, pathology, clinical pathology, and interprofessional telephone consultation chart based on the details mentioned above in three key components. 

All the above-mentioned vital components must be present in a note; if any part or subcomponent is missing, it will lead to a low-level code selection.

CPT Code For Consultation Description

The CPT code for consultation procedures are listed below.

For Clinical Pathology Consultation, CPT codes range from 80503 to 80506, which are used.

CPT 80503 is for clinical pathology consultation for a clinical problem, with limited review of the patient’s history, medical records, and straightforward medical decision-making.

CPT 80504 is for clinical pathology consultation; for a moderately complex clinical problem, with a review of the patient’s history, medical records, and a moderate level of medical decision-making.

CPT 80505 is for clinical pathology consultation; for a highly complex clinical problem requiring a comprehensive review of the patient’s history, medical records, and a high level of medical decision-making.

CPT 80506 is for clinical pathology consultation with prolonged service every additional 30 minutes.

For Inpatient Consultation, the CPT code for consultation may range from 99251 to 99255 and are used.

CPT 99251 is for inpatient consultation for a new or established patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making. In addition, counseling or coordination of care with other physicians and other QHC professionals is provided consistent with the nature of the problems and the patient’s needs. Usually, the present issues are self-limiting. Usually, twenty minutes are spent at the bedside and on the patient’s hospital floor or unit.

CPT 99252 is for inpatient consultation for a new or established patient, which requires these three key components: An expanded problem-focused history, An expanded problem-focused examination, and straightforward medical decision making. Counseling or coordination of care with other physicians, and other QHC professionals, are provided consistent with the nature of the problems and the patient’s need. Typically, the presenting problems are low severe. Usually, 40 minutes are spent at the bedside or on the patient’s hospital floor or unit.

CPT 99235 is for inpatient consultation for a new or established patient who requires these three key components: a detailed history, a detailed examination, and medical decision-making of low complexity. In addition, counseling or coordination of care with other physicians and QHC professionals is consistent with the nature of the problems and the patient’s needs. Usually, the presenting problems are moderately severe. Usually, 55 minutes are spent at the bedside and on the patient’s hospital floor or unit.

CPT 99254 is for inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history, comprehensive examination, and medical decision making of moderate complexity. In addition, counseling or coordination of care with other physicians and other QHC professionals is provided consistent with the nature of the problems and the patient’s needs. Usually, the presenting problems are of moderate to high severity. Usually, 80 minutes are spent at the bedside and on the patient’s hospital floor or unit.

CPT 99255 is for inpatient consultation for a new or established patient who requires these three key components: a comprehensive history, comprehensive exam, and medical decision-making of high complexity. In addition, counseling or coordination of care with other physicians and other QHC professionals is provided consistent with the nature of the problems and the patient’s needs. Usually, the presenting problems are of moderate to high severity. Normally, 110 minutes are spent at the bedside and on the patient’s hospital floor or unit.

For Interprofessional Telephone Consultation, the CPT code for consultation may range from 99446 to 99451.

CPT 99446 is for telephone/Internet/electronic health record evaluation and management services provided by a consulting physician, including a written or verbal report to the patient’s treating or requesting physician or other QHC professionals; this code is used for 5-10 minutes of medical consultative discussion and review.

CPT 99447 is for telephone/Internet/electronic health record assessment and management services a consulting physician provides, including a written and verbal report to the patient’s treating or requesting physician or other QHC professionals; 11-20 minutes of medical consultative discussion and review.

CPT 99448 is for telephone/Internet/electronic health record assessment and management services a consulting physician provides, including a written and verbal report to the patient’s treating or requesting physician or other QHC professionals; 21-30 minutes of medical consultative discussion and review.

CPT 99449 is for telephone/Internet/electronic health record assessment and management services provided by a consulting physician, including a written and verbal report to the patient’s treating or requesting physician or other QHC professionals; 31 minutes or more of medical consultative discussion and review.

CPT 99451 is for telephone/Internet/electronic health record assessment and management services a consulting physician provides, including a written and verbal report to the patient’s treating or requesting physician or other QHC professionals, for 5 minutes or more of medical consultative time.

For Office Consultation, the CPT code for consultation may range from 99241 to 99245 are used.

CPT 99241 is for office consultation for a new or established patient, which requires these three key components: a problem-focused history, a problem-focused examination, and straightforward medical decision-making. Counseling or coordination of care with other physicians and QHC professionals is provided consistent with the nature of the problems and the patient’s needs. Usually, the presenting problems are self-limiting. Normally, 15 minutes are spent face-to-face with the patient or family.

CPT 99242 is for an office consultation for a new or established patient that requires these three key components: An expanded problem-focused history, an expanded problem-focused examination, and straightforward medical decision-making Counseling or coordination of care with physicians and other QHC professionals is provided consistent with the nature of the problems and the patient’s needs. Usually, the presenting problems are mild to moderate. Usually, 30 minutes are spent directly face-to-face with the patient or family.

CPT 99243 is for office consultation for a new or established patient that requires these three key components: a detailed history, a detailed exam, and medical decision-making of low complexity. Counseling or coordination of care with other physicians and QHC professionals is provided consistent with the nature of the problems and the patient’s needs. Usually, the presenting problems are moderately severe. Typically, 40 minutes are spent directly face-to-face with the patient or family.

CPT 99244 is for office consultation for a new or established patient, which requires these three key components: a comprehensive history, a comprehensive exam, and medical decision-making of moderate complexity. In addition, counseling or coordination of care with other physicians and other QHC professionals is provided consistent with the nature of the problems and the patient’s needs. Usually, the presenting problems are of moderate to high severity. Normally, 60 minutes are spent directly face-to-face with the patient or family.

CPT 99245 is for office consultation for a new or established patient, which requires these three key components: a comprehensive history, a comprehensive exam, and medical decision-making of high complexity. In addition, counseling or coordination of care with other physicians and other QHC professionals is provided consistent with the nature of the problems and the patient’s or family’s needs. Usually, the presenting issues are of moderate to high severity. Normally, 80 minutes are spent face-to-face with the patient or family.

For Pathology Consultations the CPT code for consultation will be:

CPT 88321 is for consultation and report on referred slides prepared elsewhere.

CPT 88323 is for consultation and report on referred material requiring the preparation of slides.

CPT 88325 is for consultation, a comprehensive review of records and specimens, and a report on referred material.

CPT 88329 is for pathology consultation during surgery.

CPT 88331 is for pathology consultation during surgery; first tissue block, with frozen section(s), single specimen.

CPT 88332 is for pathology consultation during surgery, each additional tissue block with a frozen section.

CPT 88333 is for pathology consultation during surgery, cytologic examination (e.g., touch prep, squash prep), and initial site.

CPT 88334 is for pathology consultation during surgery, cytologic examination (e.g., touch prep, squash prep), and each additional site.

Other Consultations

CPT 77336 is for continuing medical consultation, including evaluation of treatment parameters, quality assurance of dose delivery, and patient treatment review documentation supporting the radiation oncologist’s reported therapy per week.

CPT 77370 is for special medical radiation physics consultation.

CPT 76140 is for consultation on X-ray examinations made elsewhere, with a written report.

CPT Code For Consultation Coding Guidelines

To use a CPT code for consultation, the following points are to be met:

• Request

Referring physician requests another physician for consultation. The consulting physician must include the referring physician’s name in his consultation note. Some insurance, including Medicare and Medicaid, will not pay for the consult code if the referring physician’s name is not on the consult note. 

• Render

This part presents the body of a consult note, which should include the advice or opinion of the consulting physician on the problems. The consulting physician can order the diagnostic services to analyze the disorder further and suggest any corrective actions.

• Report back

When the consulting physician reports back to the principle/referring physician, he must include the recommendation for treatment in the medical decision-making portion of his note. The report is present separately for outpatient consults, but the shared medical record can do this in the inpatient setting.

The consultation note must include the critical components as described below.

1. History

a. History of the present illness

b. Review of systems

c. Past family and social history

In the history of the present illness, the reason for consultation is mentioned clearly on a note.

The review of the system part consists of some simple questions about body systems that a patient can answer quickly; if the patient cannot answer those questions due to any medical condition, then this part will be considered complete.

A review of the system should not be confused with an examination, as both portions are similar but are used for different purposes.

2. Examination

In this portion, the consulting physician must examine the patient’s body systems in detail to form an opinion about the disorder. The provider evaluates all systems one by one, or he can determine one system in detail as per the patient-specific requirements.

3. Medical decision making

Medical decision-making is the most critical part of a consult note. Usually, this part is governed by the reason the consultation was required.

CPT Code For Consultation Modifiers

Only a limited number of modifiers are allowed with a CPT code for consultation. Each of the modifiers are explained below in detail. The coder should pay appropriate attention while appending these modifiers with consultation codes because their misuse or overuse can lead to comprehensive audits. If these modifiers are not present in a claim when required, it will not get any reimbursements.

Practical examples and applications of modifiers 24, 25, and 57 are described below.

Modifier 24 is appended with 99243 in cases where the encounter for consultation falls in the global period of any surgical procedure. The global period is categorized as 10 or 90 days as described by the coding manual, i.e., all the major surgical procedures do have a global period of 90 days. All the minor surgeries have a global period of 10 days. If the patient receives any consultation during that global period, the claim will be submitted with modifier 24. 

Modifier 57 will be applied with 99243 in the case when the decision to perform surgery was made on the same day of consultation. The same day and day before surgery are included in the global surgical package for minor and major surgical procedures. So, it will not be reimbursed separately and will be considered a part of the surgical procedure.

Modifier 25 is usually applied to general evaluation and management codes. However, consult codes are also applicable when a separately identifiable service is performed on the same day of the encounter, such as minor surgical procedures. If modifier 25 is not appended, the insurance will consider the consultation code inclusive of the other service performed on the same day and pay for it separately.

If a physician provides services in an unlisted health professional shortage area, he is subjected to appending modifier AQ to get reimbursed at higher rates. Therefore, as per government policy, insurance reimbursement for services is higher in urban areas than in rural areas.

Telehealth modifiers such as 95 and GT are also applicable with CPT 99243 when service is provided via telecommunication.

Selecting an appropriate modifier as per the situational requirements is the key to improving the first pass ratio of claims.

CPT Code For Consultation Examples

The following are examples of when a CPT code for consultation may be billed.

Example 1

A 67-year-old patient suffering from acute appendicitis is admitted to the hospital by Dr. Smith for further interventions. First, the admitting physician calls in a GI surgeon for consultation. Next, the patient was admitted and started with IV antibiotics and painkillers. The patient’s insurance is Medicare.

In this example, the patient is admitted by Dr. Smith, so the initial inpatient visit code 99222 will be billed to him. In addition, he has been called for a consultation by a GI specialist, so another initial inpatient E & M code will be billed on the same day under consulting Dr. NPI. However, the patient’s health insurance is Medicare, and it does not accept the consultation CPT codes.

If modifier AI is not appended with the principle admitting physicians’ E&M CPT code, both claims will be denied as the insurance was not notified about the consult on the same day.

Example 2

A 32-year-old patient sees Dr. Smith for a consult at the request of his PCP, Dr. Long, for an ongoing problem with allergies. The patient’s symptoms continue to worsen. Dr. Smith performs an expanded problem-focused history and exam and discusses options with the patient for allergy management.

Medical decision-making is straightforward. The patient acknowledges that he would like to be tested to possibly gain better control of his allergies. Dr. Smith sends a report to Dr. Long thanking him for the referral and including the patient’s date for allergy testing. Dr. Smith also includes his findings from the encounter. 

CPT 99242 will be used as the physician performs an expanded problem-focused history, exam, and MDM is straightforward.