Faculty Practice Plans Compliance Programs, Office of Compliance and Regulatory Affairs, Compliance Office 210-567-2014, ComplianceLine 1-877-507-7317 Faculty Practice Plans Compliance ProgramsCompliance Line 1-877-507-7317Compliance Office 210-567-2014Office of Regulatory Affairs and Compliance
 

Consultations

July 14, 2005

 

For purposes of this guideline, UT Medicine staff will follow the criteria established by CPT and CMS.

CPT defines a consultation as a type of service provided by a physician whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician.

Types of Consultations that may be billed include:

  • Outpatient Consultations - (99241-99245) - Used to report services provided in a physician's office or in an outpatient or other ambulatory facility including hospital observation, home, rest home or emergency department.
  • Inpatient Consultations - (99251-99255) - Used to report services provided to hospital inpatients, nursing home facility residents, or patients in a partial hospital setting.
  • Follow-Up Consultations - (99261-99263) - Used to report visits to complete the initial visit or as a subsequent consultative visit requested by the attending physician during the same admission. These services are only reported in an inpatient setting.
  • Confirmatory Consultations - (99271-99275) - These services may be provided in any setting and are used only when a patient or payer requests a second-opinion and restricts the physician from treating the patient in any way at that encounter.

Documentation requirements that must be met in order to qualify as a consultation service include:

  • Request -
    • The consultation is performed by a physician due to his/her expertise at the request of another physician.
    • This request must be documented in the medical record, along with the reason for the consultation. While it is not necessary to have a separate written request, the consultant should use language that clearly indicates a consult versus a request to assume management. Sample wording may include:
      • "Seen in consultation at the request of Dr. X regarding ABC;"
      • "Asked to evaluate;" or,
      • "Asked for opinion".
    • It is not acceptable to obtain referring physician information from any source other than a physician order or the actual notation in the progress note of the physician's request by the consultant.
  • Recommendation - The consulting physician must perform and document a history and exam. In addition, he/she may order or perform any tests necessary to render his/her opinion.
  • Report -
    • The consulting physician must communicate his/her opinion to the requesting physician. This must be done in a written or dictated report and must be reflected with exception being when a shared record is in use.
    • In the instances where there is a shared record between the referring physician and consultant, the report may consist of an appropriate entry (progress note) in the patient's record.

If the consultant assumes responsibility for management of a portion of or all of the patient's condition, it should be assumed that a transfer of care occurred and subsequent services should be billed as established patient visits.

Any procedure that is performed on or subsequent to the date of consultation should also be reported.

 
 
 
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