Pediatric ENT Consultation

Question:

Our internal compliance team states that our pediatric otolaryngologists should never bill for a consultation. This is because the description in the 2025 CPT states "Services that constitute a transfer of care (i.e. are provided for the management of the patient's entire care or for the care of a specific condition or problem) are reported with the appropriate new or established patient codes." I have explained that when a pediatrician refers a patient to us for ear infections, we give our opinion on what treatment is needed, perform surgery and then send the patient back to the pediatrician. If the patient has another ear infection, we ask that they see their pediatrician for management of the acute infection. I argue that what we do does not constitute a "transfer of care". They suggested I reach out to KZA for clarification. Thank you!

Answer:

CPT 2025 has removed previous language related to "transfer of care" from the consultation code section. Most payors no long accept consultation codes and require you to use problem-oriented E/M codes, but there still a few payors who pay for consults. CPT now emphasizes that consultation codes can be used when the criteria for a consult are met, regardless of whether the patient is new or established.

According to CPT, a consultation is appropriate when:

• A physician requests another physician’s opinion or advice regarding diagnosis or treatment.

• The consulting physician provides that opinion and communicates back to the requesting physician.

• The consulting physician does not assume ongoing care for the condition.

The pediatrician refers the patient for evaluation and possible surgical treatment in your case. Your team provides an expert opinion, performs the surgery, and then returns the patient to the pediatrician for ongoing care. You do not manage the patient’s long-term treatment for recurrent infections. This aligns with the definition of a consultation rather than a transfer of care. The fact that you send the patient back to the referring provider and do not assume continuous management supports your use of consult codes.  It is important to check with your individual payor to determine if they accept consultation codes are require the problem-oriented E/M codes. 

*This response is based on the best information available as of 11/20/25.