Consultation Services

Consultation Services versus Other Evaluation and Management Visits

Carriers and Part A/B Medicare Administrative Contractors (A/B MACs) pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code are met:

• A consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified non-physician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for the NPP in the state in which he/she practices. Applicable collaboration and general supervision rules apply as well as billing rules;
  
  
• A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) should be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified non-physician practitioner’s plan of care in the patient’s medical record; and
  
  
• After the consultation is provided, the consultant should prepare a written report of his/her findings and recommendations, which should be provided to the referring physician.