Glossary · Coding

Consultation codes

Consultation codes (99241–99255) are CPT evaluation and management codes used when a physician formally requests another physician's opinion on a specific clinical problem. Medicare eliminated these codes in 2010; non-Medicare payers may still accept them.

Verified May 8, 2026 · 4 sources ↓

Drawn from AoassnAAPCAAOSCMS

Definition

Source · Editorial summary grounded in 4 cited references ↓

Consultation codes are a subset of evaluation and management (E/M) CPT codes historically divided into office/outpatient consultations (99241–99245) and inpatient consultations (99251–99255). To bill any of these codes, three conditions must all be met—commonly called the 'three Rs': a request from another physician or appropriate source, a formal review and examination of the patient, and a written report sent back to the requesting provider documenting the consultant's findings and recommendations. The code level is determined by the same key components used for other E/M services—history, physical examination, and medical decision-making—with the level set by the lowest qualifying component.

The landscape changed significantly in 2010, when the Centers for Medicare & Medicaid Services eliminated consultation codes from the Medicare physician fee schedule entirely. Orthopedic surgeons seeing Medicare patients must now substitute new-patient office visit codes (99202–99205) or initial inpatient hospital care codes (99221–99223), depending on the setting. The reimbursement for these replacement codes does not always equal what the consultation codes paid, making the switch a persistent source of revenue leakage when practices fail to select the highest defensible level. Private and commercial payers vary considerably—many continue to recognize and reimburse the 99241–99255 series, so verifying each payer's policy before claim submission is essential.

Why it matters

Using a consultation code on a Medicare claim guarantees a denial, because CMS has not recognized them since 2010. That denial also triggers a rework cycle—resubmission with a corrected new-patient or initial-care code—delaying cash flow and increasing administrative burden. On the flip side, practices that default to a low-level new-patient code (e.g., 99202) when a higher-complexity visit (99204 or 99205) is fully documented leave reimbursement on the table with every Medicare consultation encounter. For commercial payers that still honor 99241–99255, failing to document the request and the written report back exposes the practice to audit recoupment, because the 'three Rs' remain the contractual standard those payers enforce.

Common mistakes

Where people most often go wrong with this concept.

Source · Editorial brief grounded in cited references ↓

Submitting CPT 99241–99255 on Medicare claims, which have not been covered since January 1, 2010, resulting in automatic denial.
Defaulting to a low-level new-patient code (99202) for all Medicare consultations instead of selecting the highest level supported by documentation.
Omitting documentation of the requesting provider's written or verbal referral request, invalidating the consultation even for commercial payers that still accept these codes.
Failing to send a written report back to the requesting physician—this is a required element for 99241–99255 and its absence is a top audit finding.
Assuming all commercial payers follow Medicare's 2010 policy; many still reimburse consultation codes, so blanket avoidance of 99241–99255 can under-code non-Medicare visits.
Conflating a referral (transfer of care) with a consultation; referrals do not qualify for consultation coding because ongoing management, not an opinion, is the intent.

Related codes

Codes commonly involved when this concept appears in practice.

CPT

Frequently asked questions

Source · Generated from the editorial pipeline, verified against 4 cited references ↓

01Can I still bill consultation codes for Medicare patients?

No. Medicare eliminated CPT codes 99241–99255 from its fee schedule on January 1, 2010. For Medicare and most Medicare Advantage plans, substitute new-patient office visit codes (99202–99205) for outpatient encounters or initial hospital care codes (99221–99223) for inpatient encounters, selecting the level that matches documented complexity.

02What are the three required elements to bill a consultation code for a non-Medicare payer?

The requesting provider's documented request for an opinion or advice, a formal evaluation of the patient by the consulting physician, and a written report sent back to the requesting provider. All three must be present in the medical record; missing any one element invalidates the consultation code.

03Can two physicians in the same practice both bill consultation codes for the same patient on the same day?

Yes, for non-Medicare payers, as long as each physician manages a distinct clinical problem, each encounter meets the three-R requirements independently, and each claim is submitted under the appropriate diagnosis pertaining to that physician's scope of service.

04What is the difference between a consultation and a referral for coding purposes?

A consultation is a request for an expert opinion on a specific problem, after which the original provider typically retains primary management. A referral involves transfer of care, meaning the receiving physician assumes ongoing management. Only consultation scenarios qualify for consultation codes; referrals are coded as new-patient visits.

05Does switching from consultation codes to new-patient codes affect how much Medicare pays?

It can. The RVU values for new-patient codes do not always equal the former consultation code values at the same clinical complexity level, so proper level selection—based on fully documented MDM or total time—is essential to recover appropriate reimbursement.

Sources & references

Editorial content was developed using the following public sources. Last verified May 8, 2026.

01
aoassn.org
https://www.aoassn.org/wp-content/uploads/2020/12/CodingTTP.pdf
02
aapc.com
https://www.aapc.com/codes/coding-newsletters/my-orthopedic-coding-alert/consult-these-guidelines-when-billing-consultations-article
03
aaos.org
https://www.aaos.org/quality/resident-guide-to-coding-and-practice-management/coding-reimbursement-for-residents/coding-articles-for-residents/
04CMS Medicare Physician Fee Schedule — elimination of consultation codes effective January 1, 2010 (CMS-1410-FC)

Mira AI Scribe

When Mira detects that an encounter is functioning as a consultation—a referring provider requested an orthopedic opinion, the note documents a focused history and exam, and a report will be sent back—it flags the payer context before suggesting a code. For Medicare and Medicare Advantage plans, Mira routes to the new-patient office visit series (99202–99205) or initial hospital care series (99221–99223) and selects the level supported by the documented MDM or time. For commercial payers whose fee schedules still include consultation codes, Mira suggests the appropriate 99241–99245 or 99251–99255 code and prompts the user to confirm that (1) a written or documented verbal request from the referring provider exists in the chart, and (2) a report back to that provider is planned or already completed. If either element is missing, Mira surfaces an inline alert before the note is finalized, reducing post-submission audit risk. Mira does not auto-select a consultation code without user confirmation of payer eligibility.

See Mira's approach