Consultations
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Defines when face-to-face medical consultations by physicians or qualified nonphysician practitioners are reimbursable under Amerigroup (Georgia) and describes documentation, coding, and nonreimbursable circumstances; applies to providers serving Amerigroup members under the listed Georgia programs.
No material clinical or coverage changes in this revision.
Consultation Coverage Criteria
Consultation coverage criteria
Covered when ALL of the following documentation, scope, examination, and reporting requirements are met; additional rules, exclusions, and special situations apply.
Preoperative or postoperative consultation reimbursement may be allowed when ALL of the following are met
- A surgeon requests the consultation as part of preoperative clearance or postoperative evaluation.
- Consultation guidelines above are met in addition to these requirements.
- For postoperative evaluation reimbursement: the requesting surgeon requires a professional opinion for treatment AND the consulting provider did not perform the preoperative clearance.
PCP exceptions (limited)
- A PCP may perform a preoperative clearance or postoperative evaluation when specifically requested by a surgeon and consultation guidelines are met; reimbursement subject to state guidance or contract and medical review as needed.
- A PCP may perform a consultation when specifically requested by a behavioral health provider for an inpatient psychiatric admission to provide a medical evaluation (history and physical) or condition-specific medical evaluation; these are usually billed as E/M visits and medical review may be required.
Non-reimbursable conditions (one or more apply)
- Consultations performed by telephone (telephone calls are not considered telemedicine) are not reimbursable.
- Split or shared E/M visits billed as consultations are not reimbursable.
- Consultations billed in addition to an E/M visit by the same provider for the same member are not reimbursable unless modifier 25 is appropriate.
- Second or third opinions requested by the member or the member's authorized representative are not reimbursable.
- Consultations for non-covered services or when the specified guidelines are not met are not reimbursable.
- Consultations are not reimbursable when a transfer of care to the consulting provider occurs or when the consulting provider performed preoperative clearance and then provided subsequent postoperative care for the same member.
Consultation Codes and Modifiers
| Consultation codes per state Medicaid guidelines or CPT as applicable; standard correct coding applies |
Reimbursement, Authorization, and Provider Requirements
Consultation reimbursement allowance
Reimbursement is allowed for face-to-face medical consultations by physicians or qualified nonphysician practitioners when the consultation guidelines are met; reimbursement is based on the fee schedule or contracted/negotiated rate and the appropriate consultation code per state Medicaid guidelines or CPT guidance.
- Consultation must be requested by the attending provider or appropriate source (written or verbal).
- Consulting provider must practice within scope and perform a personal examination of the patient.
- Consulting provider must complete a written report including member history, examination, physical findings, and recommendations.
- Medical record must include attending provider's request, reason for consultation, documentation of information communicated back to the attending provider, and the consulting provider's written report.
- Laboratory consultations must relate to test results outside clinically significant normal or expected range given the member's condition.
- If the consultant performs a definitive therapeutic surgical procedure same day, report the consultation with modifier 25 or 57 as appropriate or it is considered included in the surgical reimbursement.
Authorization, medical necessity, and coding requirements
Services must meet authorization and medical necessity guidelines appropriate to the procedure and diagnosis and be billed with proper, supported coding; failure to follow coding/billing or current reimbursement policies may result in claim rejection, denial, recovery/recoupment, or adjusted reimbursement.
- Use industry-standard CPT, HCPCS, and/or revenue codes that are fully supported in the medical record or office notes.
- Claims may be rejected or denied, payments may be recovered/recouped, or reimbursement adjusted if appropriate coding/billing guidelines or reimbursement policies are not followed.
- Policies may be superseded by provider, state, federal, or CMS mandates; services must also meet member's state authorization and medical necessity requirements.
Key Definitions
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