It is important to accurately select the level of service when submitting claims for consultations by cardiologists. A review of documentation by the Comprehensive Error Rate Testing (CERT) Documentation Contractor indicates ongoing problems with the medical record not supporting the submitted code for consultations.
Requirements for Consultations
- Consultations are distinguished from transfers of care by the three R’s:
- Request for opinion or advice from the referring physician
- Render an opinion or advice (consulting physician)
- Written report by the consulting physician to the referring physician or health care practitioner
- For each consultation CPT code, documentation must support each of the three key components of the service at the required level
- The three key components of E/M services are: History, Exam and Medical Decision Making
- You may use either the 1995 or 1997 E/M Documentation Guidelines in selecting the correct CPT code, but not both
- Cardiology consultations submitted to Medicare must meet the minimum requirements for the CPT code selected. If any one of the three key components is not documented at the required level, select a lower level of service.
- The 'Medical Decision Making' component is not the sole deciding factor in selecting the correct CPT code
- You may use time as the key or controlling factor in selecting a code only if the consultation consists predominantly of counseling or coordination of care. In other words, at least 50 percent of the time spent with the patient must be spent counseling or coordinating care in order to use time alone in selecting the CPT code.
The following tables show the requirements for each level of service for consultations:
Consultations: Office or Other Outpatient, New or Established Patient
| CPT Code | History | Exam | Medical Decision-Making | # of components required | Patient’s condition | 'Usual' time | Count time for |
| 99241 |
Problem-focused |
Problem-focused |
Straight-forward |
3 of 3 |
Self-limited or minor |
15 min. |
Face-to-face with patient and/or family |
| 99242 |
Expanded problem-focused |
Expanded problem-focused |
Straight-forward |
3 of 3 |
Problem(s) of low severity |
30 min. |
Face-to-face with patient and/or family |
| 99243 |
Detailed |
Detailed |
Low complexity |
3 of 3 |
Problem(s) of moderate severity |
40 min. |
Face-to-face with patient and/or family |
| 99244 |
Compre-hensive |
Compre-hensive |
Moderate complexity |
3 of 3 |
Problem(s) of moderate or high severity |
60 min. |
Face-to-face with patient and/or family |
| 99245 |
Compre-hensive |
Compre-hensive |
High complexity |
3 of 3 |
Problem(s) of moderate or high severity |
80 min. |
Face-to-face with patient and/or family |
Consultations: Initial Inpatient, New or Established Patient
| CPT Code | History | Exam | Medical Decision-Making | # of components required | Patient’s condition | 'Usual' time | Count time for |
| 99251 |
Problem-focused |
Problem-focused |
Straight-
forward |
3 of 3 |
Self-limited or minor |
20 min. |
Bedside plus floor/ unit time |
| 99252 |
Expanded problem-focused |
Expanded problem-focused |
Straight-
forward |
3 of 3 |
Problem(s) of low severity |
40 min. |
Bedside plus floor/ unit time |
| 99253 |
Detailed |
Detailed |
Low
complexity |
3 of 3 |
Problem(s) of moderate severity |
55 min. |
Bedside plus floor/ unit time |
| 99254 |
Compre-hensive |
Compre-hensive |
Moderate complexity |
3 of 3 |
Problem(s) of moderate or high severity |
80 min. |
Bedside plus floor/ unit time |
| 99255 |
Compre-hensive |
Compre-hensive |
High
complexity |
3 of 3 |
Problem(s) of moderate or high severity |
110 min. |
Bedside plus floor/ unit time |
Continuing Education
Palmetto GBA conducts workshops on E/M Documentation and Coding Guidelines. Click below and access Workshops to find one near you:
- Go to Workshops
- Create a Login ID and register online!
- Look for other handy resources on our Education Web page, under Workshop Handouts:
- Evaluation & Management Score Sheets
- Evaluation & Management Documentation Guidelines Educational Packet
- Hospital Evaluation & Management Services Educational Packet
Still have questions? Check out the CMS Educational Materials and Guidelines for E/M Services