Highmark Medicare Services

12102, 12202, 12302, 12501, 12301, 12201

MAC Part A & B

L27484

Consultations

L27484

CPT codes, descriptions and other data only are copyright 2007 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

Title XVIII of the Social Security Act, Section 1862(a)(1)(A) states that no Medicare payment shall be made for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury.

Title XVIII of the Social Security Act, Section 1862(a)(7).  This section excludes routine physical examinations.

Title XVIII of the Social Security Act, Section 1833(e) states that no payment shall be made to any provider for any claim that lacks the necessary information to process the claim.

CMS On-Line Manual Pub. 100-2, Chapter 15, Sections 10 and 30.

CMS On-Line Manual, Pub. 100-4, Chapter 12, Section 30.6.10.

Pennsylvania, Maryland, District of Columbia, Delaware

Central Office

For services performed on or after 07/11/2008

N/A

For services performed on or after 08/01/2008

08/31/2008

Compliance with the provisions in this policy may be monitored and addressed through post payment data analysis and subsequent medical review audits.

Carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code are met:

• A consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices. Applicable collaboration and general supervision rules apply as well as billing rules; and
  
• A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) should be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record; and
  
• After the consultation is provided, the consultant should prepare a written report of his/her findings and recommendations, which must be provided to the referring physician.

Indications

The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge. Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician or qualified NPP and the patient. The preceding requirements (request, evaluation (or counseling/coordination) and written report) must also be met when the consultation is based on time for counseling/coordination.

A consultation may not be performed as a split/shared E/M visit.

Consultation Followed By Treatment

A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, should not be reported with consultation service codes. These services should be reported as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service should be made regardless of treatment initiation unless a transfer of care occurs.

Transfer of Care

A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.

When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care to his/her service in the patient’s medical record or plan of care.

In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and should not report a consultation service.

Initial Consultation Service

Inpatient hospital or skilled nursing facility or nursing facility

In the hospital setting, the consulting physician or qualified NPP should use the appropriate Initial Inpatient Consultation codes (99251 – 99255) for the initial consultation service as described: CPT code 99251 - 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. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 20 minutes at the bedside and on the patient’s hospital floor or unit. CPT code 99252 – 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 and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presented problem(s) are of low severity. Physicians typically spend 40 minutes at the bedside and on the patient’s hospital floor or unit. CPT code 99253 – inpatient consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 55 minutes at the bedside and on the patient’s hospital floor or unit. CPT code 99254 – inpatient consultation for a new or established patient, which requires three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 80 minutes at the bedside and on the patient’s hospital floor or unit. CPT code 99255 – inpatient consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 110 minutes at the bedside and on the patient’s hospital floor or unit.

The Initial Inpatient Consultation may be reported only once per consultant per patient per facility admission.

Initial Consultation Service

Office or other outpatient setting

In the office or other outpatient setting, the consulting physician or qualified NPP should use the appropriate Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) for the initial consultation service as described: CPT code 99241 – 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 and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family. CPT code 99242 – office 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 and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 30 minutes face-to-face with the patient and/or family. CPT code 99243 – office consultation for a new or established patient, which requires these three key components: a detailed history; a detailed examination; and medical decision making of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 40 minutes face-to-face with the patient and/or family. CPT code 99244 – office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 60 minutes face-to-face with the patient and/or family. CPT code 99245 – office consultation for a new or established patient, which requires these three key components: a comprehensive history; a comprehensive examination; and medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 80 minutes face-to-face with the patient and/or family.

If an additional request for an opinion or advice, regarding the same or a new problem with the same patient, is received from the same or another physician or qualified NPP and documented in the medical record, the Office or Other Outpatient Consultation (new or established patient) codes (99241 – 99245) may be used again. However, if the consultant continues to care for the patient for the original condition following his/her initial consultation, repeat consultation services should not be reported by this physician or qualified NPP during his/her ongoing management of this condition.

Follow-Up Consultation Service

In the hospital setting, following the initial consultation service, the Subsequent Hospital Care codes (99231 – 99233) should be reported for additional follow-up visits.

In the nursing facility setting, following the initial consultation service, the Subsequent Nursing Facility (NF) Care codes (99307 – 99310) should be reported for additional follow-up visits.

In the office or other outpatient setting, following the initial consultation service, the Office or Other Outpatient Established Patient codes (99212 – 99215) should be reported for additional follow-up visits. The CPT code 99211 should not be reported as a consultation service. The CPT code 99211 is not included by Medicare for a consultation service since this service typically does not require the presence of a physician or qualified NPP and would not meet the consultation service criteria.

Second Opinion E/M Service Requests

A second opinion E/M service is a request by the patient and/or family or mandated (e.g., by a third-party payer) and not requested by a physician or qualified NPP. A consultation service requested by a physician, qualified NPP or other appropriate source that meets the requirements for consultation services should be reported using the initial consultation service codes. A written report is not required by Medicare to be sent to a physician when an evaluation for a second opinion has been requested by the patient and/or family.

A second opinion, for Medicare purposes, is generally performed as a request for a second or third opinion of a previously recommended medical treatment or surgical procedure. A second opinion E/M service initiated by a patient and/or family is not reported using the consultation codes.

In both the inpatient hospital setting and the NF setting, a request for a second opinion would be made through the attending physician or physician of record. If an initial consultation is requested of another physician or qualified NPP by the attending physician and meets the requirements for a consultation service the appropriate Initial Inpatient Consultation code should be reported by the consultant. If the service does not meet the consultation requirements, then the E/M service should be reported using the Subsequent Hospital Care codes (99231 – 99233) in the inpatient hospital setting and the Subsequent NF Care codes (99307 – 99310) in the NF setting.

A second opinion E/M service performed in the office or other outpatient setting should be reported using the Office or Other Outpatient new patient codes (99201 – 99205) for a new patient and established patient codes (99212 – 99215) for an established patient, as appropriate. The 3 year rule regarding “new patient” status applies. Any medically necessary follow-up visits should be reported using the appropriate subsequent visit/established patient E/M visit codes.

The CPT modifier -32 (Mandated Services) is not recognized as a payment modifier in Medicare. A second opinion evaluation service to satisfy a requirement for a third party payer is not a covered service in Medicare.

Consultations Requested by Members of Same Group

Payment may be made for a consultation if one physician or qualified NPP in a group practice requests a consultation from another physician in the same group practice when the consulting physician or qualified NPP has expertise in a specific medical area beyond the requesting professional’s knowledge. A consultation service should not be reported on every patient as a routine practice between physicians and qualified NPPs within a group practice setting.

Consultation for Preoperative Clearance

Preoperative consultations are payable for new or established patients performed by any physician or qualified NPP at the request of a surgeon, as long as all of the requirements for performing and reporting the consultation codes are met and the service is medically necessary and not routine screening.

Postoperative Care by Physician Who Did Preoperative Clearance Consultation

If subsequent to the completion of a preoperative consultation in the office or hospital, the consultant assumes responsibility for the management of a portion or all of the patient’s condition(s) during the postoperative period, the consultation codes should not be used postoperatively. In the hospital setting, the physician or qualified NPP who has performed a preoperative consultation and assumes responsibility for the management of a portion or all of the patient’s condition(s) during the postoperative period should use the appropriate subsequent hospital care codes to bill for the concurrent care he or she is providing. In the office setting, the appropriate established patient visit codes should be used during the postoperative period.

A physician (primary care or specialist) or qualified NPP who performs a postoperative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code for evaluation and management services furnished during the postoperative period following surgery when all of the criteria for the use of the consultation codes are met and that same physician has not already performed a preoperative consultation.

Surgeon’s Request That Another Physician Participate In Postoperative Care

If the surgeon asks a physician or qualified NPP who had been treating the patient preoperatively or who had not seen the patient for a preoperative consultation to take responsibility for the management of an aspect of the patient’s condition during the postoperative period, the physician or qualified NPP may not bill a consultation because the surgeon is not asking the physician or qualified NPP’s opinion or advice for the surgeon’s use in treating the patient. The physician or qualified NPP’s services would constitute concurrent care and should be billed using the appropriate subsequent hospital care codes in the hospital inpatient setting, subsequent NF care codes in the SNF/NF setting or the appropriate office or other outpatient visit codes in these settings.

Limitations

Consultations requested by oral surgeons, psychologists, or podiatrists who are permitted by hospital by-laws to admit patients should be honored when medically necessary. However, mandatory consultations required by hospital rules and regulations are not covered.

Services that do not meet the guidelines outlined in the "Indications and Limitations of Coverage and/or Medical Necessity" section of this policy.

Consultation services performed by a provider who does not possess an expertise and knowledge base over and above that of the referring provider with regard to the specific nature of the consultation request will be denied as not reasonable and necessary.

Services that are not supported by medical record documentation.

Doctor Office Visits, Hospital Care (Inpatient), Skilled Nursing Facility Care, Outpatient Hospital Services, Second Surgical Opinions

Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type. Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination. Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

N/A

Conditions that are not listed in the "ICD-9-CM Codes that Support Medical Necessity" section of this policy.

1. All documentation must be maintained in the patient’s medical record and available to the contractor upon request.
   
   
2. Every page of the record must be legible and include appropriate patient identification information (e.g., complete name, dates of service(s)).  The record must include the physician or non-physician practitioner responsible for and providing the care of the patient.
   
   
3. The submitted medical record should support the use of the selected ICD-9-CM code(s).  The submitted CPT/HCPCS code should describe the service performed.
   
   
4. A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient's medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation must be documented in the patient's medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.
   
   
5. The reason for the consultation service must be documented by the consultant (physician or qualified NPP) in the patient's medical record and included in the requesting physician or qualified NPP's plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.
   
   
6. Documentation requirements for the Consultation Report:
   • A written report should be furnished to the requesting physician or qualified NPP.
     
   • In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician or qualified NPP and the consultant, the request may be documented as part of a plan written in the requesting physician or qualified NPP's progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record.
     
   • In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or qualified NPP or if the consultant's records show a specific reference to the request. In this setting, the consultation report is a separate document communicated to the requesting physician or qualified NPP.
     
   • In a large group practice, e.g., an academic department or a large multi-specialty group, in which there is often a shared medical record, it is acceptable to include the consultant's report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP to the requesting physician or qualified NPP. The written request and the consultation evaluation, findings and recommendations shall be available in the consultation report.

In accordance with CMS Ruling 95-1 (V), utilization of these services should be consistent with locally acceptable standards of practice.

Other Contractor’s Policies

Highmark Medicare Services Contractor Medical Directors

This policy does not reflect the sole opinion of the contractor or Contractor Medical Directors. Although the final decision rests with the contractor, this policy was developed in cooperation with advisory groups, which includes representatives from the appropriate specialty (ies).

CAC/IAC Distribution:  04/01/2008

05/15/2008

05/23/2008

L27484

07/31/2008

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