CPT Q&A

Q:What are the documentation requirements associated with inpatient consultations (99251-99255) and outpatient consultations (99241-99245)?

A: The verbal or written request for the consultation must be documented in the patient's medical record. The consultant's opinion and any services that are performed must also be documented in the patient's medical record and communicated to the requesting health care provider. A“ consultation” initiated by a patient and/or family member, and not requested by a physician, is not reported using the initial consultation codes but may be reported using the codes for confirmatory consultation (99271-99275) or office visits (99201-99215), as appropriate.

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