Ensure compensation for consultations: Making sense of CPT codes 99446-99452

Physicians spend a significant amount of time discussing patient care options with other physicians. In 2014, CPT codes 99446 to 99449 were created to capture the time consultants spend on behalf of a patient who is not present. Information can be exchanged using either the telephone or the internet.

Earlier this year, two more codes were added with this same purpose in mind and a third method of communication, the EHR, was added. CPT codes 99451 and 99452 report the services of providers who work together on behalf of a patient, using any of the three modes of communication. Code 99451 is reported by the consultant, and code 99452 is reported by the treating/requesting provider.

Interprofessional telephone/internet/EHR consultations: CPT codes 99446-99452

These codes are intended to describe assessment and management services conducted through phone, internet or EHR consultation furnished when a patient’s treating physician or qualified health professional (QHP) requests the opinion or treatment advice of a consulting physician or QHP with specific expertise to assist with diagnosis or care management without the need for the patient to be present.

Consultant codes

These codes require that the request and the reason for the request for the consult be documented in the record. They cannot be reported more than once per seven days for the same patient but can include cumulative time spent, even if the time occurs on subsequent days. They cannot be reported if a transfer of care or request for a face-to-face consult occurs as a result of the consultation within the next 14 days or if the patient was seen by the consultant within the past 14 days.

• CPT codes 99446-99449 — Interprofessional telephone/internet assessment and management service provided by a consultative physician including a verbal and written report to the patient’s treating/requesting physician or other qualified healthcare professional; 5-10 minutes of medical consultative discussion and review. Additional time may be billed using 99447 (11-20 minutes), 99448 (21-30 minutes), 99449 (31 minutes or more).
• CPT code 99451 — Interprofessional telephone/internet/electronic health record assessment and management service provided by a consultative physician including a written report to the patient’s treating/requesting physician or other qualified healthcare professional, 5 or more minutes of medical consultative time.

Treating/requesting physician code

• CPT code 99452 — Interprofessional telephone/internet/electronic health record referral service(s) provided by a treating/requesting physician or qualified healthcare professional, 30 minutes. This code includes time preparing for the referral and/or communicating with the consultant but cannot be reported for a transfer of care. It requires a minimum of 16 minutes and can be reported with non-direct prolonged services (99358-99359) if appropriate. The code cannot be reported more than once per 14 days per patient. 

Billing requirements

• Billing practitioner: Billing is limited to those practitioners who can independently bill Medicare for E/M services.
• Consent and documentation: Consent must be documented in the medical record by the treating practitioner and the patient must be made aware of any cost-sharing obligations. Practices may document that verbal consent was received.
• Benefit of the patient: To be separately payable, consultations must be for the benefit of the patient. CMS explains this reimbursement is not intended for activities undertaken for the benefit of the practitioner, such as professional courtesy or continuing education.

These services are not considered to be Medicare telehealth services; as such they are not subject to statutory restrictions, such as originating site limitations, rural geographic requirements, qualifying technology requirements and place of service codes and modifiers.1

The new interprofessional consultation codes, which are accomplished by telephone, over the internet or via the EHR, should not be confused with the CPT consultations codes 99241 to 99255, which have been around for decades. They were eliminated by CMS in 2010 but may be accepted by other payers.

A consultation is a type of E/M service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or for the care of a specific condition or problem. No distinction is made between new and established patient for consultation services.

A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit. Of vital importance: The written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient’s medical record by either the consulting or requesting physician or appropriate source. The consultant’s opinion and any services that were ordered or performed also must be documented in the patient’s medical record and communicated by written report to the requesting physician or other appropriate source.

In the office setting, the consultant should use the appropriate office or other outpatient consultation codes and the established patient office or other outpatient service codes thereafter. In the hospital or partial hospital setting, the consultant should use the appropriate inpatient consultation code for the initial encounter and subsequent hospital service codes thereafter.

In the outpatient setting, if an additional request for an opinion regarding the same or new problem is received from another physician or appropriate source, the office consultation codes may be used again. In the inpatient or partial hospital setting, only one consultation should be reported by a consultant per admission.

Services that constitute transfer of care are reported with the appropriate E/M service code.

Transfer of care is the process whereby a physician or other QHP who is providing management for some or all of the patient’s problems relinquishes this responsibility to another physician or other QHP who explicitly agrees to accept this responsibility.2

Consultation codes should not be reported by the physician who has agreed to accept transfer of care before an initial evaluation but are appropriate to report if the decision to accept transfer of care cannot be made until after the initial consultation evaluation.

Consultations, whether requiring direct or indirect patient contact, are an indispensable means of providing comprehensive, quality care. In a world of decreasing revenue and increasing demands on time, it’s nice to know that some of this effort can be compensated.

Notes:

1. Centers for Medicare & Medicaid Services. “CY 2019 PFS Final Rule.” 129-137.
2. “CPT® 2019 Standard Edition.” Chicago: American Medical Association. 2019.