Clinical consultations are paid under the physician fee schedule only if they:
a. Are requested by the patient’s attending physician;
b. Relate to a test result that lies outside the clinically significant normal or expected range in view of the condition of the patient;
c. Result in a written narrative report included in the patient’s medical record; and
d. Require the exercise of medical judgment by the consultant physician.
Clinical consultations are professional component services only, i.e., there is no TC service. The clinical consultation codes are 80500 and 80502.
Routine conversations held between a laboratory director and an attending physician about test orders or results do not qualify as consultations unless all four requirements are met. Laboratory personnel, including the director, may from time to time contact attending physicians to report test results or to suggest additional testing or be contacted by attending physicians on similar matters. These contacts do not constitute clinical consultations. However, if in the course of such a contact, the attending physician requests a consultation from the pathologist, and if that consultation meets the other criteria and is properly documented, it is paid under the fee schedule.
EXAMPLE: A pathologist telephones a surgeon about a patient’s suitability for surgery based on the results of clinical laboratory test results. During the course of their conversation, the surgeon asks the pathologist whether, based on test results, patient history and medical records, the patient is a candidate for surgery. The surgeon’s request requires the pathologist to render a medical judgment and provide a consultation. The pathologist follows up his/her oral advice with a written report and the surgeon notes in the patient’s medical record that he/she requested a consultation. This consultation is paid under the fee schedule.
In any case, if the information could ordinarily be furnished by a nonphysician laboratory specialist, the service of the physician is not a consultation payable under the fee schedule.
See the Program Integrity Manual for guidelines for related data analysis to identify inappropriate patterns of billing for consultations.
