Consult Documentation Guidelines

by  Codapedia
December 11th, 2015

By Jeannie Cagle, BSN, RN, CPC
For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following:
·         There must be written documentation in the chart from the physician practice requesting the consult. You can have them fax a request or the patient can bring it with them, but as the physician billing the consult, you have to make sure you have the request in writing.
·         The written report that must be sent to the requesting physician is the most often overlooked component of a consult code. This report does not have to be a full copy of the history, exam, and decision making but can be a summary of your opinion and recommendation for treatment. Most requesting providers would prefer not to have the full consultation note; it’s too much reading; duplicates information they already have in their own history, and takes up too much space in the chart. Make sure you maintain documentation in your chart that shows that the opinion was sent either by mail or fax or email.
·         Primary care or cardiology physicians who are asked to clear a patient for surgery can bill a consult code, even if the clearance is for an established patient. Remember that for Medicare patients, surgery clearance is only covered for patients with an underlying medical condition such as hypertension or diabetes that must be managed to safely perform surgery. Most carriers suggest the use of V72.83 diagnosis code for pre-operative surgery clearance. Remember that the requirements for written request from requesting physician and the need to send back your opinion to the requesting physician still apply.
·         Medicare has made it very clear that consults CANNOT be shared between non-physician practitioners and physicians. If a non-physician practitioner performs any of the key elements of the consult, then the consult cannot be billed under the physician NPI. For commercial carriers, be sure and find out if these visits can be shared--don't just assume that they can.
Once you get your processes in place to ensure you are following the rules for consult coding, you can put more energy into patient care. Happy coding!


Consult Documentation Guidelines. (2015, December 11). Find-A-Code Articles. Retrieved from

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