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Evaluation and Management:

Office Visit vs. Consultation


As we all know, the use of CPT codes are for identifying purposes for reporting medical services and procedures performed by physicians.  Here we address some commonly used codes which are just as commonly used in error!  


Horrifyingly, some surgical physicians stick to a simple rule: any patient they see for the first consultation will be coded as 99245 and subsequent consultations are always billed as 99244 regardless of the amount of time spent with the patient face-to-face.  The cringe factor has slid well and truly off the wall and into a deep muddy pool of eau-de-cringe; a cologne nobody wants to wear especially when the auditors come for a visit, and this visit, I can assure you, will not be for a cup of coffee and a donut or indeed – short!


I am sure almost everyone reading this is using the latest edition of the CPT code book.  Most books today have very clear, precise and understandable definitions.


So what exactly is the difference between an Office Visit and a Consultation?  Quite simple:  an Office Visit is for the evaluation and management of a patient, where as a Consultation is the same but at the request of another physician or appropriate source.  Remember, when a patient initiates a “consultation” without the request of another physician or appropriate source, this is considered a Confirmatory Consultation; Second or Third Opinion.  In a confirmatory consultation, the physician is expected to give an opinion or advise ‘only’; any subsequent services are coded at the appropriate level of office visit.  Don’t forget to use modifier 32 if a confirmatory consult is required by a third party payor.


Inpatient Consultations are quite obviously when the patient has been admitted to a hospital, residents of nursing facility or in a partial hospital setting.  Only one initial consultation is allowed per admission. 


Follow-up inpatient consultations are visits needed to complete the initial consultation or subsequent consultative visits requested by the attending physician.  If the consulting physician initiated treatment at the initial consultation and continues to participate in the patients care, the codes for subsequent hospital care should be used.


Don’t forget, when a surgeon sees a patient after surgery, watch for the “global” rule.  Also, make sure you use the correct modifier for pre surgical consultation when performed with the 24 hour rule.  If the correct modifier is not used the claim will not be paid.


Code Review:


     Office or Other Outpatient Services:

    New Patient: 99201 - 99205

    Established Patient: 99211 – 99215



    New/Established Patient: 99241 - 99245


     Confirmatory Consultations:

        New/Established Patient: 99271 - 99275


     Initial Inpatient Consultations:

    New/Established Patient: 99251 - 99255