Whether you can code a consultation code or must use Emergency Department (ED) codes (99281-99285) depends on the insurance payer and whether consultation documentation standards are met.
Here is how code selection works for an ED consultation:
1. Commercial / Private Payers (When Consults are Recognized)
- CPT Consultation Codes (99242-99245): Commercial plans that adhere to standard CPT guidelines allow outpatient consultation codes to be billed in Place of Service 23 (Emergency Room).
- The “3 Rs” Requirement: To bill 99242-99245, the chart must document a formal Request for an opinion/advice, the service Rendered/Reviewed, and a written Report sent back to the requesting provider.
2. Medicare & Payers That Do Not Recognize Consults
- Crosswalk to ED Codes (99281-99285): Medicare strictly does not reimburse CPT consultation codes (99242-99245) for Part B claims.
- If the patient has Medicare, or if the “3 Rs” documentation criteria are not fully met, you must crosswalk the service to the standard ED E/M codes based on Medical Decision Making (MDM) complexity:
3. Special Scenario: Consultant Admits the Patient
- If a consultant is called to the ED and decides to admit the patient to inpatient or observation status, you cannot bill an ED visit/consult and an admission on the same day for the same provider.
- Instead, the ED evaluation work is rolled into the admitting History and Physical (H&P) note and billed using Initial Hospital Care codes (99221-99223).