Medicare Compliance & Reimbursement - 2017 Issue 7
E/M: Master the Rules for Consultation and Referral Billing
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Article Overview
This article covers the difference between referral and consultation scenarios in E/M billing and why those distinctions matter for reimbursement, compliance, and documentation. It is aimed at coders, billers, auditors, and clinicians who handle office and inpatient E/M services, especially when payer policies differ from standard consultation coding. The discussion includes general guidance on recognizing transfer-of-care situations, documenting requested consultative services, and navigating Medicare-related handling of consultation claims and related hospital care reporting.
Why This Topic Matters
Correctly identifying whether a service is a referral or a consultation can affect claim selection, payment level, and compliance risk. The article is especially relevant where Medicare or other payer rules alter the usual approach to consultation and hospital E/M reporting.
Article Sections
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Learn This Ironclad Referral Rule
Explains the broad distinction between referral and transfer-of-care scenarios and how that affects general E/M code selection for office services.
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Finesse Consultation Opportunities
Covers the general features of consultation services, documentation expectations, and the impact of payer policies on office and inpatient consultation reporting.
What You Will Learn
- How referral and consultation scenarios differ in E/M billing
- What documentation themes are associated with consultative services
- How payer policy can change reporting for office and inpatient E/M cases
- Why Medicare treatment of consultation services matters for claim selection
- How hospital E/M reporting may be affected when consultation codes are not recognized
Who Should Read This
- Medical coders
- Billing staff
- Compliance auditors
- Physician practices
- Hospital revenue cycle teams
- Surgeons and other clinicians involved in E/M documentation
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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