Coding and Billing for “Consultation” Codes

Marty Kotlar, DC, CHCC, CBCS

I’ve heard of “consultation” codes, but I’m not sure how to use them. Are they used when I do consultation or does an MD have to refer the patient to me?

First of all, I must congratulate you for not being willing to just “guess” or “gamble” with proper CPT coding. Nowadays, it is extremely important to become better educated on proper billing, coding, compliance and documentation. The insurance reimbursement aspect of most chiropractic practices has changed drastically over the last 8-10 years.

A DC can bill for consultation codes. Consultation codes require another healthcare provider to request your opinion or advice on the evaluation and management of the patient. On the initial visit, the DC must perform a history, examination, make medical decision-making (MDM), etc. and then write and send a report to the referring healthcare professional (i.e., MD, DO, DC, nurse practitioner, physical therapist, psychologist). On this visit, the DC may also want to initiate diagnostic and/or therapeutic services. Remember, at this point you are “co-treating” the patient with the referring provider so you’ll want to document this patient encounter very, very well 

When the referring provider “transfers” the responsibility for treatment to the DC at the time of the referral, the DC cannot continue to bill a consultation visit. He or she would bill an appropriate established patient code (99211-99215). A consultation may be reported if the referring physician does not transfer the responsibility for the patient’s care to the receiving physician until after the consultation is completed.

Consultations requested by members within the same group are eligible for payment as long as all of the requirements for use of the consultation codes are met. A consultation initiated by a patient and/or family member and not directly requested (in writing or verbally) from a healthcare professional, is reported using the office visit codes, not the consultation codes.

The CPT codes for outpatient consultations are as follows:

99241: Office consultation for a new or established patient, which requires these three key components:

  • a problem focused history;
  • a problem focused examination; and
  • straightforward medical decision making.

Counseling with/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are self limited or minor. Physicians typically spend 15 minutes face-to-face with the patient and/or family.

99242: Office consultation for a new or established patient, which requires these three key components:

  • an expanded problem focused history;
  • an expanded problem focused examination; and
  • straightforward medical decision making.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of low severity. Physicians typically spend 30 minutes face-to-face with the patient and/or family.

99243: Office consultation for a new or established patient, which requires these three key components:

  • a detailed history;
  • a detailed examination; and
  • medical decision making of low complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate severity. Physicians typically spend 40 minutes face-to-face with the patient and/or family.

99244: Office consultation for a new or established patient, which requires these three key components:

  • a comprehensive history;
  • a comprehensive examination; and
  • medical decision making of moderate complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presenting problem(s) are of moderate to high severity. Physicians typically spend 60 minutes face-to-face with the patient and/or family.

99245: Office consultation for a new or established patient, which requires these three key components:

  • a comprehensive history;
  • a comprehensive examination; and
  • medical decision making of high complexity.

Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the presently problem(s) are of moderate to high severity. Physicians typically spend 80 minutes face-to-face with the patient and/or family.

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Dr. Marty Kotlar, president of Target Coding, has helped hundreds of chiropractors during the last 12 years to improve reimbursement through proper and compliant CPT coding. For more information call 800-270-7044, visit or email .