CMS issues coding guidance for consultations

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Note:  The following article synopsis was NOT provided by HCPro. It was created by Find-A-Code/innoviHealth.

Article Overview

This article covers CMS guidance on consultation reporting after CPT deletions, with attention to office, hospital, and nursing facility settings. It is relevant to coders, billing staff, physicians, and qualified nonphysician practitioners who need to understand Medicare’s documentation and reporting framework for consultation services. The article also discusses second opinions, request-and-response requirements, transfer-of-care distinctions, and updated consultation-related documentation expectations.

Why This Topic Matters

Consultation billing changed when CPT deleted certain consultation codes, and CMS issued guidance to clarify how Medicare expects these services to be reported. Understanding the article helps practices reduce claim errors and align documentation with Medicare’s consultation rules.

Article Sections

  1. Followup consultations and second opinions

    This section discusses Medicare guidance for follow-up and second-opinion consultation reporting across office, hospital, and nursing facility settings. It also addresses related consultation reporting considerations for different encounter types.

  2. Consultations by NPPs

    This section covers CMS guidance on consultation services provided by qualified nonphysician practitioners and the related documentation expectations. It also addresses request, report, and transfer-of-care concepts in general terms.

What You Will Learn

  • How CMS frames consultation reporting after CPT consultation deletions
  • Which broad care settings are addressed in the guidance
  • What documentation themes CMS highlights for consultations
  • How Medicare guidance addresses consultations performed by qualified nonphysician practitioners
  • How transfer of care is distinguished from a consultation request

Who Should Read This

  • Medical coders
  • Billing staff
  • Physicians
  • Nonphysician practitioners
  • Practice managers

Codes Discussed

Code Ranges Discussed

  • CPT: 99261–99263
  • CPT: 99271–99275
  • CPT: 99231–99233
  • CPT: 99307–99310
  • CPT: 99311–99313
  • CPT: 99212–99215
  • CPT: 99201–99205

Modifiers Discussed


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