Physician must perform all elements of consult, including HPI

Why This Topic Matters

Understanding these rules helps practices avoid billing errors, support compliant consultation documentation, and preserve the level of service when appropriate history is obtained and recorded by the physician.

Article Sections

1. Consultation documentation and physician-performed history

   This section discusses the need for ophthalmologists to complete and document key consultation elements themselves. It also addresses the role of history-taking in supporting consultation billing.

2. Medicare on split/shared visits

   This section summarizes Medicare treatment of split/shared evaluation and management services in office and hospital settings. It distinguishes the general visit categories discussed in the article without providing code-specific guidance.

3. Ancillary staff and history components

   This section reviews how ancillary staff may assist with certain history components and how physicians may document them. It also reinforces the article’s focus on physician documentation of the history of present illness.