Consultation is requested by the attending provider or appropriate source (written or verbal).
Consulting provider performs the consultation within their scope and includes a personal examination of the patient.
Consulting provider completes a written report that includes member history (including chief diagnosis/complaint), examination, physical findings, recommendations for future management and/or ordered services, the attending provider's request and reason for the consult, and documentation of communication to the attending provider and member's authorized representative.
Member medical record contains the attending provider's request for the consultation, the reason for the consultation, documentation of information communicated to the attending provider and authorized representative, and the consulting provider's written report.
Laboratory consultations are reimbursable only when related to test results that are outside the clinically significant normal or expected range given the member's condition.
If the consulting provider performs a definitive therapeutic surgical procedure on the same day as the consultation for the same member, the consultation must be reported with modifier 25 or 57 as appropriate; if the appropriate modifier is not reported the consultation is considered included in the surgical reimbursement and is not separately reimbursable.
PCP exceptions: A primary care physician (PCP) may perform a reimbursable consultation when specifically requested by a surgeon for preoperative clearance or postoperative evaluation, provided consultation and pre/postoperative guidelines are met and state/contract allowances apply; routine PCP care generally does not qualify as a consultation.
Same group practice: A consultation within the same group practice may be reimbursable if requested from another provider of a different specialty or subspecialty and consultation guidelines are met.
Postoperative consultation reimbursement limits: A consulting provider may be reimbursed for a postoperative evaluation only if the requesting surgeon requires a professional opinion for treating the member and the consulting provider has not performed the preoperative clearance; postoperative visits are concurrent care and do not qualify if preoperative clearance was performed by the same consulting provider and postoperative care is transferred to that same provider.
Nonreimbursable consultations: Not reimbursable: consultations performed by telephone; split/shared E/M visits; additional E/M by same provider for same member unless modifier 25 applies; second/third opinions requested by the member; consultations for non-covered services; when transfer of care to consulting provider occurs; both preoperative clearance and postoperative evaluation for same member by same consulting provider; or when specified guidelines are not met.
Preoperative visits are usually included in the surgeon's global surgical allowance; medical review may be required if a PCP is reimbursed for services normally included in the global fee allowance.