AAOS Bulletin - April, 2006

2006 E&M code change overview

By Mary LeGrand, RN, MA, CCS-P, CPC

As office-based services and reimbursement become more integral parts of an orthopaedic practice’s financial results, correct use of the 2006 Current Procedural Terminology (CPT) Evaluation and Management (E&M) codes is essential.

In 2006, the following E&M consultation categories were deleted:

• Confirmatory consultation codes (99271–99273), traditionally reported when a patient or third party sought a “second opinion” regarding a surgical recommendation or plan of care

• Follow-up inpatient consultation codes (99261–99263), used to report follow-up visits in the hospital to complete the initial consultation or if the surgeon was reconsulted during the same hospital stay

As a result, your office should remove CPT codes 99271–99275 and 99261–99263 from encounter forms and hospital charge cards/tickets and disable these codes in the Practice Management system. Palm Pilots or other electronic charge capture tools should also be updated to reflect the deletion of these codes.

Coding replacement options

If a patient or third party self-refers for a second opinion, the most appropriate codes are the new patient codes (99201–99205) or the established patient codes (99211–99215), depending on whether or not the criteria for a new or established patient visit is met.

Review payer reimbursement policies for second opinions requested by patients and/or third parties.

In the hospital setting, orthopaedic surgeons will use the appropriate subsequent hospital care codes (99231–99233) when providing subsequent E&M services to complete the initial consultation or when reconsulted during the same hospital stay.


CPT also revised the introductory guidelines for reporting consultation codes requested by a physician or other appropriate source. The following guideline change (with changes shown in bold and italics) states:

“If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient’s condition(s), the appropriate Evaluation and Management services code for the site of service should be reported. In the hospital setting, the consulting physician should use the appropriate inpatient hospital consultation code for the initial encounter and then subsequent hospital care codes. In the office setting, the appropriate established patient code should be used.”1

This means you should report the appropriate consultation code (99241–99245 for outpatient consultation or 99251–99255 for inpatient consultation) when a physician requests your opinion or advice regarding evaluation and/or management of a specific problem. For follow-up visits, use the appropriate established patient codes—99211–99215 (outpatient) or 99231–99233 (subsequent hospital care codes).

Medicare code changes

In late December, Medicare released Transmittal 788, CR 4125 revising the old policy found in the Medicare Claims Processing Manual, Pub.100-04, Chapter 12, Section 30.6.10. This transmittal addressed the deletion of CPT codes 9927x and 9926x and clarified the definition, documentation requirements, when and by whom a consultation may be performed/reported, and split/shared evaluation and management services.

According to the transmittal, “The intent of a consultation service is that a physician/nonphysician provider (NPP) or other appropriate source is asking another physician/NPP for advice, opinion, recommendation, suggestion, direction, or counsel, etc., in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.”

If a physician is asked to see a patient for whom the physician has previously provided a consultation service, the physician may report a consultation again if: (1) the consultation request is to evaluate a new condition or (2) the referring physician reconsults the physician for the same condition and the consulting physician is not providing ongoing management of that condition.

A split/shared visit may not be performed or reported as a consultation service. Nonphysician providers (physician assistants, nurse practitioners and clinical nurse specialists) may perform and report consultation services when requirements are met. An NPP may independently perform a consultation within the scope of practice and licensure regulations and must meet the applicable collaborative and supervision rules.

Do not report a consultation service if the physician and NPP each perform a part of the history, examination and medical decision making. This is a shared/split service and the work may not be shared/combined between providers. One provider must perform the entire history, examination and medical decision making. Report the service using the unique provider identification number of the provider who performed the entire service.

The request and reason for the consultation shall be documented by the consultant in the patient’s medical record. It also must be documented in the requesting provider’s plan of care. Dictate the reason for the visit as a request for evaluation at the request of the referring provider. For example, “Patient is seen at the request of Dr. PCP for evaluation of knee pain.”

The provider who is seeing the patient in consultation must send the requesting provider a written report that includes the consulting provider’s findings and recommendations.

The provider who is consulted may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Report appropriate established patient visit codes when patient is seen in follow-up to the initial consultation.

Transfer of Care

A transfer of care occurs when a physician or NPP requests that another physician or NPP take over the responsibility for managing the patient’s complete care for the condition, and does not expect to continue treating or caring for the patient for that condition.

When this transfer is arranged, the requesting provider is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or NPP shall document this transfer of the patient’s care in the patient’s medical record or plan of care. If a transfer of care occurs, report the appropriate new or established patient visit code based on place of service.

Document the request for consultation as the chief complaint and the findings of the evaluation service in the plan of care. Instruct patient to return to his or her primary care provider for his or her ongoing general medical care.

Documentation requirements

A written request for a consultation and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting and consulting physicians and must be documented in both medical records: “As a result of our phone call on Feb. 3, I evaluated Mrs. Hip today at your request . . . ”

In a service setting (emergency room, inpatient or outpatient) where the medical record is shared between the referring and the consulting physician or NPP, the request may be documented as part of a plan in the requesting provider’s progress notes, as an order in the medical record or as a specific written request for the consultation.

In the office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or NPP. In this case, the consultation report is a separate document communicated to the requesting physician or NPP.

In a large group practice, such as an academic department or a large multispecialty group, which has a shared medical record, the consultant’s report in the shared medical record is acceptable and a separate letter is not required.

Intragroup consults

A physician or NPP in a group practice may report a consultation service if the consulting physician or NPP has expertise in a specific medical area beyond the requesting professional’s knowledge.

A consultation service shall not be reported on every patient as a routine practice between physicians or NPPs within a group practice setting.

Next steps

Perform an audit of your consultation services to determine if your documentation is consistent with the revised Medicare policy guidelines. Ensure a written report is sent to all providers who request consultations. If your current dictation includes a letter as both the written report and office note of the day, separate the two.

These changes are significant and every office should pay careful attention to these new rules. They represent potential problems in documenting the request for consultation.


1. 2006 AMA Current Procedural Terminology, Chicago, AMA Press, 2005.

Mary LeGrand, RN, MA, CCS-P, CPC is a consultant and instructor for the Mastering Orthopaedic Coding course sponsored by the AAOS in conjunction with KarenZupko and Associates.

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