You have seen consultation codes mentioned in passing in the level-selection and hospitalist chapters; this chapter is where they get the full treatment, so if you came here from one of those cross-references, this is the complete picture.
A thoughtful consultation, reviewing the records, examining the patient fresh, writing a real opinion back to a colleague, is some of the most cognitively demanding work in medicine, and the codes that recognize it are worth understanding. Consultation codes (CPT 99241–99245 for outpatient, 99251–99255 for inpatient) have a complicated status in modern billing. Medicare eliminated payment for them effective January 1, 2010, and instructed physicians to substitute standard E/M codes in their place. Most commercial payers still recognize and pay consultation codes. Understanding this split is essential for any specialist who sees referred patients.
The Three Requirements for a Consultation
For the consultation code to apply, for commercial payers that recognize it, three elements must be present:
1. Request: Another physician or qualified health professional requested the consultation. This request should be documented, typically a referral note, order, or documented phone/electronic communication in the record.
2. Rendering service: You performed the consultation and documented it appropriately, with an E/M evaluation supporting the level billed under the consultation code range.
3. Report back: You communicated your findings and recommendations back to the requesting physician. This can be a formal written consultation note, a letter, or a documented message. It cannot be omitted.
If any of these three elements is missing, the encounter cannot be billed as a consultation, it defaults to a standard new or established patient E/M.
Medicare's Approach: Use Standard E/M Codes
For Medicare patients, what would have been billed as a consultation is billed as a new patient office visit (99202–99205) if it is the first visit, or an established patient visit (99212–99215) if the patient is established. The E/M level is determined by MDM or time, exactly as for any other office visit.
To be precise about the values: new-patient office codes carry higher work RVUs than the established-patient code at the same level, not lower. For example 99204 (new, level 4) is 3.00 wRVUs versus 99214 (established, level 4) at 1.92; 99203 is 1.60 versus 99213 at 1.30. The new-patient work is valued higher because of the added effort of a first encounter. So the rule to remember is: same level, new patient pays more, which is exactly why the new-versus-established determination is worth getting right.
The Outpatient Consultation Code Levels
Outpatient consultation codes follow the same MDM-or-time logic as standard E/M codes since the 2023 revisions aligned them with the 2021 framework. Note that 99241 was deleted in 2023, paralleling the deletion of 99201:
| CPT | MDM Level | Time Threshold |
|---|---|---|
| 99242 | Straightforward | 20 min |
| 99243 | Low | 30 min |
| 99244 | Moderate | 40 min |
| 99245 | High | 55 min |
For commercial payers that recognize these codes, the moderate and high consultation levels reimburse at or above the equivalent new patient codes, which is why specialists with heavy commercial referral volume should not default to new patient E/M codes for everything.
Inpatient Consultations
Inpatient consultation codes (99251–99255) follow the same three-element rule, request, render, report back, for commercial payers. For Medicare inpatients, the substitution is the initial hospital or observation care codes (99221–99223). The level of these codes, like all E/M codes post-2021, is based on MDM or time.
Telehealth Consultations
Consultation codes can be used for telehealth services when the same three requirements are met and the clinical evaluation supports the level billed. The standard telehealth documentation requirements apply (Modifier 95 or 93 depending on the modality), and the payer must cover telehealth consultations, which varies significantly by payer and state.
The Same Referral, Two Payers
A cardiologist sees a patient referred by their primary care physician for evaluation of palpitations, with a clear request for opinion and a report back to the referring physician. For a commercial payer that still recognizes consultation codes, this is reported as an office consultation. For Medicare, which stopped recognizing consult codes, the identical encounter is reported as a standard new or established office visit instead. Same work, same documentation, different code depending on the payer. The practical discipline is knowing which of your payers still accept consults and coding each accordingly, rather than defaulting to one habit for everyone.