HealthCare News

Consults – Outpatient and Inpatient

Issue: #398 DEC2017

Topic: Coding/Billing


Blue Cross Blue Shield of North Dakota (BCBSND) will not accept consultation CPT® codes 99241-99245 or 99251-99255. These consultation codes will be non-covered as provider-liable services. The denial reason will instruct the provider to resubmit with a more appropriate E&M code. These guidelines must be followed when billing consultation services:

Consults in the office or as an outpatient: These services should be submitted using the new or established patient office or other outpatient visit codes 99201-99215. New and established patient visit criteria remains according to the CPT® definition. Services must meet the CPT® code definition.

Consults in the emergency room (ER): When a consultation takes place in the ER, the service may be submitted as either an additional ER visit or as an outpatient office visit using the appropriate place of service code (23 for ER). Documentation must support the CPT® code definition.

Consults during observation: Only the admitting physician can use the initial observation care codes 99218-99220. Other physicians performing a consult should use the new or established patient office or other outpatient visit codes.

Consults during an inpatient hospital stay: The first time a physician sees a patient in consult, an initial hospital care code (99221-99223) may be billed regardless of when the visit occurs during the inpatient stay. There may be multiple initial hospital care codes on the admit date or other date depending on the physician(s) who assesses the patient in consult. However, there should never be more than one initial hospital care code per physician. Subsequent visits to the patient must be billed using subsequent care codes 99231-99233.

The admitting physician must append modifier AI to the initial hospital care code to identify the admitting physician of record. There should only be one initial hospital care code with modifier AI. Any additional initial care codes with this modifier will be noncovered as a duplicate service.

When a second physician sees a patient as an initial consult and all the required components are performed and documented, an initial hospital care code may be used (99221-99223). If the criteria for an initial hospital care code is not met and the documentation and criteria supports a subsequent hospital care code (99231- 99233), those codes should be used even if an initial code has not been submitted by that physician. Only rarely would code 99499 (unlisted E&M service) be used if documentation does not meet criteria for subsequent care. Documentation must establish that a medically necessary service was rendered and where the service took place. Claims submitted for services with code 99499 will be individually reviewed.

Consults in a nursing facility: The first time a physician sees a nursing facility patient in consult, an initial nursing facility care code (99304-99306) may be billed regardless of when the visit occurs during the nursing facility stay. Multiple initial nursing facility care codes may be billed depending on the physician(s) who assesses the patient in consult. However, there should never be more than one initial nursing facility care code per physician. Subsequent visits to the patient must be billed using subsequent care codes 99307-99310.

The admitting physician must append modifier AI to the initial nursing facility care code to identify the admitting physician of record. There should only be one initial nursing facility care code with modifier AI. Any additional initial care codes with this modifier will be non-covered as a duplicate service.

When a second physician sees a patient as an initial consult and all the required components are performed and documented, an initial nursing facility care code may be used (99304-99306). If the criteria for an initial nursing facility care code is not met and the documentation and criteria supports a subsequent nursing facility care code (99307-99310), those codes should be used even if an initial code has not been submitted by that physician. Only rarely would code 99499 (unlisted E&M service) be used if documentation does not meet criteria for subsequent care. Documentation must establish that a medically necessary service was rendered and where the service took place. Claims submitted for services with code 99499 will be individually reviewed.

Consults submitted on a UB-04: Any of the consultation codes submitted on the UB-04 will be non-covered as provider liable services. The denial reason will instruct the provider to resubmit with a more appropriate E&M code.