Inpatient and outpatient office consultations (CPT procedure codes 99241-99255) are covered when provided to a member at the request of another provider and when medically necessary and appropriate. If an additional request for an opinion or advice regarding the same or a new problem for the same member is received from a second provider and documented in the medical record, the consultation procedure codes may be used again by the consulting provider. Any qualified provider may request a consultation.
If the consulting provider assumes responsibility for management of a portion or all of the member's medical condition, the use of consultation procedure codes is no longer appropriate by that provider. The provider should then use the appropriate level E&M code for the POS.
For a "consultation" initiated by the member or member's family (e.g., a request for a second surgical opinion) and not requested by a provider, the "consulting" provider should use the appropriate level E&M code, rather than consultation procedure codes.
An E&M consultation requires face-to-face contact between the consultant and the member, either in person or via telehealth, where appropriate. A consultation must always result in a written report that becomes a part of the member's permanent medical record.
Claims for consultations must include the referring provider's name and NPI.