Consultation Policy

Policy: Consultations-Outpatient Clinic Based Visits

Policy

It is the policy of SIU, SIU SOM and SIU P&S to consistently and fully comply with all laws and regulations pertaining to the deliver of and billing for services, which apply to SIU, SIU SOM and SIU P&S on account of their participation in Medicare, Medicaid and other government programs.

I.       Background:

SIU, SIU SOM and SIU P&S is committed to ensuring that its billing and documentation policies and procedures adhere to all federal and state compliance regulations.  The following rules apply to performing, documenting and billing for outpatient consultations.

Note:  These rules apply to physicians, nurse practitioners and physician assistants when requirements are met.

Definition of a Consultation: Patient evaluation provided by a physician whose opinion or advice regarding evaluation and management of a specific problem is requested by another physician or appropriate source.  Nurse practitioners, physician assistants or certified nurse-midwives (hereinafter referred to as “Appropriate Source”), may request a consultation if it is within their scope of practice.  A determination of whether the visit is a consultation is determined by the requesting physician.

Transfer of Care: Occurs when the referring physician transfers the responsibility for the patient’s complete care of a particular condition to the receiving physician at the time of the referral.

Please see the attached flow chart to distinguish between a consultation and a transfer of care.

II.     Policy:

A.     Documentation:

1. A request for a consultation from an Appropriate Source and the reason for the consultation must be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified non-physician practitioner’s plan of care in the patient’s medical record.

2. After the consultation is provided, the consultant must prepare a written report of his/her findings and recommendations, which must be provided to the referring physician.

3. Residents are not an appropriate source in requesting a consultation.

B. A consultation may not be performed or billed as a split/shared E/M visit.

C. Consultation services may not be billed for every patient as a routine practice.

D. An Appropriate Source consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit.  Ongoing management, following the initial consultation service by the consultant physician, shall not be reported with consultation service codes.  These services shall be reported as subsequent visits for the appropriate place of service and level of service.

E. Consultations requested by members of the same group:

1. Consultations can be within the same group if one physician or an Appropriate Source in a group practice requests a consultation from another physician in the same group practice in accordance with this policy. 

2. A consultation service may not be billed on every patient as a routine practice.

3. Documentation requirements for consultation requests between members in the same group practice are the same as in Section IIA.

4. Consultations cannot be requested within the same division of the group practice.