What are the rules for billing consultations?

What are the rules for billing consultations?

What are the rules for billing consultations?

As a medical billing professional, it’s essential to understand when a consultation can be billed, who can provide one, and how to properly document and submit these services based on CPT and payer guidelines.

Who Can Provide a Consultation?

Consultation services can be performed by:
  1. Physicians
  2. Nurse Practitioners (NPs)
  3. Physician Assistants (PAs)
As long as:
  1. The service is within their scope of practice under state law
  2. Any supervision or collaboration requirements are followed
  3. The payer accepts consultation codes (Note: Medicare does not pay for consult codes, but many private payers still do)
Also, per CPT guidelines, consultations may be requested by other licensed providers (e.g., social workers, physical therapists) or even non-clinical sources like insurance companies or lawyers.

Key Documentation Requirements: The 4 R’s

To bill a consultation (e.g., CPT 99241–99245 or 99251–99255), the medical record must clearly include these four elements:
1. Request – The request must come from another qualified provider or source and be documented in both the requesting and consulting provider’s chart.
2. Reason – Include the clinical rationale for the consult.
3. Render – The consultant must perform and document services that meet the E/M guidelines (history, exam, and medical decision-making—or time, if applicable).
4. Report – A written report must be sent back to the requesting provider. If both use the same shared record, it can be documented in the patient’s chart.
Warning
If any of these elements are missing, a standard E/M service should be billed instead.

What Isn’t a Billable Consultation?

Understanding what doesn’t qualify is just as important.

The following are not consultations:
  1. Transfers of care – When a provider assumes complete care without giving an opinion first
  2. Self-referrals from patients or family members
  3. Internal group referrals used routinely
  4. Post-op care assignments without request for advice
  5. Split/shared visits (not allowed for consults)
  6. Billing a 99211 as a consult
  7. More than one consultation billed per provider per hospital admission

Medicare Rules: No Consultation Payment

Medicare no longer reimburses for CPT consultation codes. For Medicare patients, use new or established patient E/M codes based on place of service (office, outpatient, inpatient, etc.).
Info
Always verify whether a payer still covers consult codes before billing.

Pre-Operative Consultation Billing

Surgeons often request preoperative clearance from a primary care provider or specialist. This can be billed as a consultation if:
  1. There’s a documented request from the surgeon
  2. The provider gives an opinion on whether the patient is medically stable for surgery

In This Case Use:
  1. The appropriate consultation E/M code based on setting and complexity
  2. Diagnosis codes for:
    1. The reason for surgery (e.g., knee osteoarthritis)
    2. Any findings from the consult (e.g., hypertension)
If the consulting provider continues to manage a condition post-op, switch to follow-up or concurrent care codes after the consult visit.

Billing Tips for Consultation Services

  1. Always review payer policies before using consult codes
  2. Ensure all 4 R’s are documented before selecting a consultation CPT code
  3. When in doubt, default to E/M codes for new or established patients
  4. Educate your providers: consultations require more than just referrals—they require a formal request for advice or opinion

Notes
Consultation billing is only appropriate when specific documentation and request requirements are met. As a biller, you play a critical role in ensuring correct coding and preventing denied claims by verifying that all elements of a consult are present and that payers will reimburse for it.

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