Medicare_Claims_Processing_Manual / 4215

Why This Topic Matters

Consultation reporting rules changed with the 2006 CPT updates, and this guidance helps readers understand the Medicare-specific framework surrounding those changes. It matters because consultation, follow-up, and second-opinion services are handled differently depending on setting and documentation, affecting claims processing and compliance.

Article Sections

1. General Information

   Introduces the transmittal, its effective and implementation dates, and the broad policy context for the consultation service updates.

2. Business Requirements

   Summarizes the administrative implementation framework and references related operational requirements.

3. Supporting Information and Possible Design Considerations

   Lists implementation support topics such as dependencies, interfaces, and testing considerations.

4. Schedule, Contacts, and Funding

   Provides timing, contact, and funding information associated with the transmittal.

5. Consultation Services versus Other Evaluation and Management (E/M) Visits

   Defines consultation services in relation to other E/M services and describes the general documentation framework.

6. Consultation Followed by Treatment

   Addresses how consultation services are considered when diagnostic services or treatment begin after the initial consult.

7. Initial and Follow-Up Consultation Services

   Covers initial consultation reporting and the handling of later visits in different care settings.

8. Second Opinion E/M Service Requests

   Discusses second opinion requests and how they are treated in Medicare settings when consultation requirements are or are not met.

9. Consultations Requested by Members of Same Group

   Explains consultation requests within group practice settings and the general conditions for those services.

10. Documentation for Consultation Services

    Reviews the documentation expectations for consultation requests and consultation reports across care environments.

11. Consultation for Preoperative Clearance

    Addresses consultation services requested for preoperative evaluation and the general billing context for those services.

12. Postoperative Care by Physician Who Did Preoperative Clearance Consultation

    Describes postoperative care considerations when the consultant continues involvement after a preoperative consultation.

13. Surgeon’s Request That Another Physician Participate In Postoperative Care

    Covers requests for postoperative participation by another clinician and the general reporting implications.

14. Examples That Meet the Criteria for Consultation Services

    Provides illustrative scenarios showing consultation situations that meet the manual’s criteria.

15. Examples That Do Not Meet the Criteria for Consultation Services

    Provides illustrative scenarios showing situations that do not qualify as consultation services.