what is physician consulation?


A consultation is the advice or opinion of one physician to another. A consultation is primarily per- formed at the request of a referring physician. The consultant examines the patient and prepares a report of his or her findings, which is provided to the referring physician for use in treating the pa- tient. If the intent of the visit is to see the patient and provide the referring physician with advice or an opinion, then consultation procedure codes are used.

Documentation requirements for consultations include:

History, examination, and medical decision making components to support the level of care billed;

A written report, provided to the attending/referring physician for inclusion in the patient ’ s per- manent medical record; and

A statement in the requesting physician ’ s record on advice or opinion being sought.

The request and the need for advice or opinion must be documented in the patient ’ s medical record. The consultant ’ s opinion/advice and any services or tests performed should also be documented and communicated to the referring physician.

A consultant may initiate diagnostic treatments and/or therapeutic services. However, if the consult- ant assumes responsibility for the patient, he or she should then use appropriate procedure codes for established or subsequent patient visits, based on the place of service, rather than consultation proce- dure codes.

* All consultation codes billed to Medicare must contain the referring physician ’ s name and Unique Physician/Practitioner Identification Number (UPIN) AND NPI

* Not all consultations are initiated by a referring physician. The patient and/or family member may initiate a confirmatory consultation, to obtain a second or third opinion. The physician per- forming the service should use his or her name, NPI and UPIN in the appropriate areas on the claim.

* Any identifiable procedure or service performed on or subsequent to the date of the initial con- sultation should be reported separately.

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