Crystal's MCW Coder HubMedicare Consults — Coding & Billing Guide
Critical Rule
Medicare does not recognize consultation CPT codes (99241-99255). These codes were eliminated from the Medicare Physician Fee Schedule effective January 1, 2010 (CMS Transmittal 1875). Billing consult codes to Medicare will result in claim denial.
1. Background — Why Medicare Eliminated Consult Codes
Prior to 2010, physicians used consultation codes (99241-99245 for office/outpatient and 99251 - 99255 for inpatient) to report services rendered at the request of another provider. CMS eliminated these codes citing:
- Widespread documentation confusion over what constituted a “true” consult vs. a new patient visit
- Payment disparity concerns — consult codes paid more than equivalent new patient E/M codes
- Concerns about duplicate billing between the requesting and consulting physician
- Desire to simplify E/M coding and reduce administrative burden
Important
CMS redistributed the relative value units (RVUs) from the eliminated consult codes into new patient office visit codes and initial hospital care codes to maintain budget neutrality.
2. What Replaced Consult Codes for Medicare?
2a. Outpatient / Office Setting
| Scenario | Code(s) to Use |
|---|---|
| New patient seen in office/outpatient at request of another provider | 99202-99205 (Office/Outpatient New Patient E/M) |
| Established patient seen in office/outpatient at request of another provider | 99212-99215 (Office/Outpatient Established Patient E/M) |
New vs. Established
The 3-year rule still applies. A patient not seen by the physician (or any physician of the same specialty in the same group practice) within the past 3 years is considered a new patient.
2b. Inpatient Hospital Setting
| Scenario | Code(s) to Use |
|---|---|
| First day of hospital care — consulting physician sees patient for the first time | 99221-99223 (Initial Hospital Care) |
| Subsequent days — consulting physician sees same patient again on later dates | 99231-99233 (Subsequent Hospital Care) |
| Patient discharged same day consulting physician provided service | 99234-99236 (Observation or Inpatient Care, Admission and Discharge Same Date) |
One Initial Hospital Care Code Per Admission Per Physician
2c. Nursing Facility Setting
| Scenario | Code(s) to Use |
|---|---|
| New patient / first encounter in nursing facility | 99304-99306 (Nursing Facility Care, Initial) |
| Subsequent encounters in nursing facility | 99307-99310 (Nursing Facility Care, Subsequent) |
2d. Critical Care
If a consulting physician provides critical care services, they may bill:
Note
Critical care may be billed by multiple physicians on the same date only if they are of different specialties and providing critical care for different conditions.
3. Key Documentation Requirements (Medicare)
Even though consult codes are gone, the clinical circumstances of a consultation still matter for documentation integrity. CMS and MACs may audit records to confirm medical necessity.
The consulting physician’s note should still capture:
- Reason for referral — Who requested the consult and why (referral source, clinical question)
- History — HPI, PMH, ROS, medications, allergies as medically appropriate
- Physical Examination — Relevant to the clinical question
- Medical Decision Making (MDM) or Time — Per 2023 AMA E/M guidelines (see below)
- Impression and Plan — The consulting physician’s assessment and recommendations
- Communication back to requesting provider — Best practice; may be required by payer policies and Joint Commission standards (written or verbal)
Written Report Requirement Eliminated by Medicare
Medicare no longer requires the written report back to the requesting physician as a billing requirement (this was a consult code requirement). However, it is still strongly recommended for clinical continuity and risk management.
4. E/M Level Selection — 2023 AMA Guidelines
Since 2021 (outpatient) and 2023 (inpatient), E/M level is determined by Medical Decision Making (MDM) or Total Time — not by history and exam counting.
4a. Medical Decision Making (MDM) — 3 Elements
MDM is based on the highest level met in at least 2 of 3 elements:
| MDM Element | Straightforward | Low | Moderate | High |
|---|---|---|---|---|
| Number & Complexity of Problems | Minimal | Low | Moderate | High/Severe |
| Amount/Complexity of Data | Minimal/None | Limited | Moderate | Extensive |
| Risk of Complications/Morbidity | Minimal | Low | Moderate | High |
4b. Total Time (Inpatient, on date of encounter)
Time on the Date of the Encounter
For inpatient E/M, total time includes all time spent on the floor/unit on that calendar date — reviewing records, ordering, care coordination, and face-to-face time. It does not include time in other locations (e.g., reviewing records at home later that evening).
5. Split/Shared Visits (Inpatient)
When a physician and an NPP (Nurse Practitioner or Physician Assistant) both provide a portion of an E/M visit on the same date for the same patient:
- The visit may be billed under the physician or NPP, depending on who performs the substantive portion
- Effective January 1, 2024, the substantive portion is defined as more than half of the total time OR the key portion of MDM (as defined by CMS)
- Must document both providers’ names and that it was a split/shared visit
- Billed under the provider who performed the substantive portion using their NPI
6. Incident-to Billing — Does NOT Apply Inpatient
Warning
Incident-to billing does not apply in the hospital inpatient, hospital outpatient, or nursing facility setting. It only applies in the office/clinic setting. Each provider in the inpatient setting bills under their own NPI.
7. Specialty-Specific Notes
7a. Urology Consults
- When a Urologist is asked to consult on hematuria, BPH, kidney mass, etc., bill the appropriate initial hospital care (99221-99223) or new patient office E/M (99202-99205) based on setting
- Urologists frequently perform procedures at the time of or following the consult — bill procedure codes separately if not bundled (check NCCI edits)
- Common bundling issues: cystoscopy (52000) with E/M — use ]] on the E/M if a separately identifiable E/M was performed on the same day as a procedure
- Modifier -25 = Significant, Separately Identifiable E/M Service by the Same Physician on the Same Day as a Procedure
7b. Ophthalmology Consults
- Ophthalmologists have the unique option to use either standard E/M codes (99202-99215) or Eye Visit codes (92002-92014) for office visits — not both on the same date
- For inpatient consults, Ophthalmology uses the same 99221-99223 / 99231-99233 codes as all other specialties — Eye codes are outpatient only
- When performing an inpatient consult for acute angle-closure glaucoma, post-op complications, or trauma, bill initial hospital care under the Ophthalmologist’s NPI
- Modifier -25 is critical when a procedure (e.g., foreign body removal, I&D of chalazion, YAG laser) is performed same day as an E/M
7c. Otolaryngology (ENT) Consults
- ENT consults are commonly requested for airway management, epistaxis, head/neck masses, sinusitis, and hearing/balance evaluation
- Inpatient ENT consults bill 99221-99223 for initial encounter; 99231-99233 for subsequent
- Flexible nasolaryngoscopy (31575) is frequently performed at the bedside during inpatient consults — bill with Modifier -25 on the E/M if it meets the criteria for a separate service
- Post-procedural care globally included in some procedures — confirm global period before billing a separate E/M
8. Non-Medicare Payers — Important Distinction
Check Each Payer's Policy
| Payer Type | Consult Codes (99241-99255) |
|---|---|
| Medicare | ❌ Not accepted — use E/M codes |
| Medicaid | Varies by state — check MAC/State policy |
| Commercial (BCBS, Aetna, UHC, etc.) | ✅ Usually accepted — verify by payer |
| TRICARE | ✅ Generally accepted |
| Workers’ Comp | Varies by state |
9. Modifiers Relevant to Consult Scenarios
| Modifier | Description | When to Use |
|---|---|---|
| -25 | Significant, separately identifiable E/M on same day as procedure | When a consult/E/M and a procedure occur same day |
| -57 | Decision for surgery made at this E/M visit | When E/M on day before or day of major surgery led to decision to operate |
| -AI | Principal Physician of Record | Used by the admitting physician to distinguish from consulting physicians on initial hospital care |
| -GC | Service performed in part by resident under teaching physician supervision | Teaching hospital inpatient consult situations |
| -GE | Service performed by resident without presence of teaching physician | For primary care exception in teaching settings |
| -95 | Synchronous telemedicine service | When consult is rendered via telehealth |
10. Modifier AI — Critical for Inpatient Consults
When multiple physicians bill initial hospital care (99221-99223) for the same patient on the same admission:
- The admitting/attending physician appends Modifier AI to their 99221-99223 to identify themselves as the Principal Physician of Record
- Consulting physicians do NOT use Modifier AI — they simply bill the appropriate initial hospital care code without it
- This allows Medicare to process multiple 99221-99223 claims for the same beneficiary without denial, as long as they are from different specialties
Example
11. Common Claim Denial Reasons — Consult-Related
| Denial Reason | Likely Cause | Resolution |
|---|---|---|
| CO-4 / CO-B7 | Consult code billed to Medicare | Recode to appropriate E/M; resubmit |
| CO-97 / NCCI Bundling | E/M bundled with procedure, no Modifier -25 | Add Modifier -25 to E/M if separately identifiable |
| CO-18 / Duplicate | Two physicians in same specialty billed initial hospital care same day | Confirm correct code; ensure different specialties |
| CO-50 | Not medically necessary | Strengthen documentation to support MDM level billed |
| CO-4 | Invalid/missing modifier | Review modifier usage; add AI if applicable |
12. Telehealth Consults (Medicare)
Medicare expanded telehealth coverage significantly post-COVID. As of current policy:
- Outpatient telehealth consult → bill 99202-99215 with Place of Service 02 (telehealth, non-originating site) or POS 10 (telehealth, patient home) and Modifier -95
- Inpatient telehealth is more restrictive — verify current CMS telehealth code list annually, as these change with each MPFS final rule
- Audio-only visits are covered with specific modifiers under certain circumstances — verify annually
13. Quick Reference Summary
MEDICARE CONSULT CODING — QUICK LOOKUP
SETTING | FIRST ENCOUNTER | SUBSEQUENT
-----------------|---------------------|-------------------
Office/Outpatient| 99202-99205 (new) | 99212-99215 (est.)
Inpatient Hosp. | 99221-99223 | 99231-99233
Nursing Facility | 99304-99306 | 99307-99310
Critical Care | 99291 | 99292 (add-on)
KEY MODIFIERS:
- -AI → Admitting physician only (not consultants)
- -25 → E/M same day as procedure
- -57 → Decision for surgery
- -95 → Telehealth
14. References & Resources
- CMS Transmittal 1875 (Elimination of Consult Codes)
- CMS Medicare Claims Processing Manual, Chapter 12
- AMA CPT E/M Guidelines 2023
- CMS MLN Booklet: Evaluation and Management Services
- CMS NCCI Edits
- CMS Telehealth Services List (updated annually)
Last reviewed: 2026-03-20 | Always verify against the current year’s MPFS Final Rule and your MAC’s LCDs.