decisionhealth Newsletters, Answer Books - 2006 Issue 7 (July)
Medicare_Claims_Processing_Manual / Chapter_12 / 30.6.10
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Article Overview
This article explains Medicare’s consultation policy within the Medicare Claims Processing Manual, Chapter 12. It covers when consultation services are recognized, what documentation is expected, how consultations relate to subsequent treatment or postoperative care, and how different practice settings affect reporting. The article is intended for physicians, coders, billers, and compliance staff who work with evaluation and management services and referral-based care.
Why This Topic Matters
Consultation policy affects whether a service is payable as a consultation or must be reported differently based on the care setting and relationship between the clinicians involved. Understanding the manual guidance helps reduce claim errors and support compliant documentation.
Article Sections
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A - Consultation Versus Visit
Introduces the distinction between a consultation and other types of visits and summarizes the general documentation expectations tied to referral-based services.
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B - Consultation Followed by Treatment
Addresses how initial consultations are treated when the consultant also becomes involved in ongoing care, including changes in reporting based on transfer of care and setting.
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C - Consultations Requested by Members of Same Group
Discusses consultation requests within a group practice and notes the role of limited licensed practitioners in requesting services.
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D - Documentation for Consultations
Summarizes recordkeeping and reporting requirements for consultation requests and written reports in different care settings.
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E - Consultation for Preoperative Clearance
Covers consultation services requested for preoperative clearance in office or hospital settings.
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F - Postoperative Care by Physician Who Did Preoperative Clearance Consultation
Explains how postoperative management affects reporting when the same physician provided the preoperative consultation.
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G - Surgeon’s Request That Another Physician Participate In Postoperative Care
Addresses postoperative participation requested by a surgeon and the distinction between consultation and concurrent care.
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H - Examples of Consultations
Provides illustrative consultation scenarios across specialties and settings, including examples involving emergency, office, inpatient, and postoperative care.
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I - Examples That Do Not Satisfy the Criteria for Consultations
Lists situations that do not meet consultation criteria, focusing on documentation and service context.
What You Will Learn
- How Medicare distinguishes consultation services from other evaluation and management visits
- What general documentation is expected for consultation requests and reports
- How consultation reporting is affected when treatment begins after the initial consult
- How consultation policy applies across office, hospital, emergency, preoperative, and postoperative settings
- Which scenarios are presented as examples of consultation use and non-use
Who Should Read This
- Physicians
- Medical coders
- Medical billers
- Compliance staff
- Revenue cycle staff
Code Ranges Discussed
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