Medicare_Carriers_Manual / 15506 / 15506

Why This Topic Matters

Consultation billing is a frequent source of claim denials and compliance questions because documentation, referral relationships, treatment responsibility, and setting all affect how services are reported. This guidance helps readers recognize the broad Medicare framework governing consultations and related evaluation and management service reporting.

Article Sections

1. Ed. Note: For further information see

   A brief editorial note pointing readers to related consultation, visit, and referral materials.

2. 15506. Consultations (Codes 99241 - 99275)

   General Medicare policy for consultation services, including how consultations are distinguished from visits and the documentation expectations associated with them.

3. A. Consultation Versus Visit

   General criteria used to distinguish consultation services from office or other visit services.

4. B. Consultation Followed By Treatment

   Policy considerations when a consultation is followed by ongoing treatment or transfer of care across settings.

5. C. Consultations Requested By Members Of Same Group

   Guidance on consultation requests within the same group practice and the role of non-physician practitioners.

6. D. Documentation for Consultations

   Documentation expectations for consultation requests and written reports in shared and non-shared record settings.

7. E. Consultation for Preoperative Clearance

   Policy for preoperative consultation services requested by a surgeon.

8. F. Post-Operative Care By Physician Who Did Pre-Operative Clearance Consultation

   Guidance addressing postoperative management after a preoperative consultation and related reporting considerations.

9. G. Surgeon’s Request That Another Physician Participate In Post-Operative Care

   Policy for postoperative participation by another physician when the request is for management rather than consultation.

10. H. Examples of Consultations

    Illustrative consultation scenarios across office, hospital, emergency, and specialty referral settings.

11. J. Examples That Do Not Satisfy the Criteria for Consultations

    Illustrative situations that do not meet consultation criteria under the cited Medicare guidance.