By Jimmie Hebert, CPC, CMCA-EM, CMC, CMOM, CMIS
There is a very specific difference between a new patient office visit (99202-99205) vs a consultation office visit (99242-99245). The same applies to the initial inpatient visit codes (99221-99223) vs the inpatient consultation codes (99252-99255).
The American Medical Association (AMA) CPT rules apply to all providers to include faculty and APPs that have billing Evaluation and Management codes within their scope of practice. When APPs are working with faculty, they are considered as working in the exact same specialty and subspecialty as the physician. For those insurance plans that do not recognize consultation codes, Epic has logic that will convert the chosen consultation code to the equivalent office visit or inpatient visit type and level of service. The AMA has a 3-year rule to determine if a patient is new or established that we must follow.
New Patient:
- Faculty or APP sees a patient for the first time today
a. Patient has not been seen by another faculty or APP of exact same specialty and subspecialty within the UTMB group within the last 3 years.
Established Patient:
- Faculty or APP sees a patient for the first time today
a. Patient has been seen by faculty or APP of the exact same specialty and subspecialty within the UTMB group within the past 3 years.
Codes 99242-99245 are office consultations visit codes. Your patient may be a new or an established patient to bill these codes. These codes require a requesting provider. You may not bill these codes unless another provider has requested advice or opinion concerning the patient’s health issue. This may be done via a verbal or written request from the requesting practitioner here at UTMB or outside the UTMB group. A consultation also requires the results of the consultation to be relayed to the requesting practitioner.
Required Documentation:3 R’s of Consultations: Request, Reason, Report
- Request: The medical record must document a request for an opinion or advice from an appropriate source e.g., physician, or qualified healthcare professional.
- Reason: The specific problem or reason for the consultation must be clearly documented in the patient record.
- Example:1. Some providers will link the Epic order to the encounter.
2. Others will document in this information in the encounter note
“Consultation requested by (Practitioner) for (Reason)” - Report: Will include the normal elements necessary for an E/M and must include the practitioner’s advice, opinion, and any services ordered/performed. This information must be communicated via a written report to the requesting practitioner.