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How to Differentiate Between Consultation and Pre-Procedure Encounter

Physician clinicians commonly interact with their patients before and after their procedures and subsequently bill patients for that time. As with most medical billing, there are guidelines which provide when a physician may bill under an Evaluation and Management Services (E/M) code in addition to the procedure code, and when the physician may only bill one code or the other.

The guidelines advise that if the physician-patient encounter is at the request of another physician and the purpose of the visit is to evaluate the patient and determine the course of treatment, it is billable as an E/M service using the appropriate E/M code set. Conversely, if the encounter is a pre-procedure visit and merely completed in order to obtain informed consent, it is not a unique E/M service and should not be separately billed in addition to the procedure code.

In accordance with the guidelines, a consultation/pre-procedure consultation requires three specific elements to qualify as a unique E/M service:

  • The physician must receive a referral or request for consultation from a proper source that is documented by both the referring and consulting physicians in the patient’s medical record;

  • CMS’ three key elements that define a patient encounter must occur – history, examination, and medical decision making – and should be well-documented in the patient’s medical record; and

  • the consulting physician should send the referring/requesting physician a report of the patient encounter that is either contained in the patient’s medical record or drafted as a separate letter.

However, not all E/M services may be separately billed. The guidelines generally state that a pre-procedure visit that is completed in order to prepare a patient for the procedure is typically included in the reimbursement for the procedure itself. Such an encounter may be designed to evaluate a patient’s status, complete a recent patient history or a current physical exam, and obtain informed consent prior to the procedure. These visits are considered “bundled” into the fee for the procedure itself. Because these patient interactions do not qualify as unique E/M services, they should not be billed as such.

In addition to ensuring the services provided match the requirements under the specific E/M code, the service must also be considered “reasonable and necessary” in order to be considered for reimbursement by Medicare. The practitioner must ensure the codes selected to be billed accurately reflect the furnished services.

Regardless of whether the patient visit qualifies as a separately-billable consultation or a pre-procedure encounter, the guidelines urge physicians to thoroughly document the work completed during each patient visit, as well as the purpose of each visit, in the patient’s medical record. The decision then lies with the individual physician to determine whether the visit qualifies as unique and should be separately billed, or the visit was merely a pre-procedure encounter that falls under the umbrella of reimbursement for the procedure itself.

© 2019 BARNES & THORNBURG LLP

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About this Author

Anne B. Compton-Brown, Barnes Thornburg Law Firm, Atlanta and Chicago, Health Care Law Attorney
Associate

Anne B. Compton-Brown is an associate in the Atlanta and Chicago offices of Barnes & Thornburg LLP and a member of the firm’s Healthcare Department and Data Security and Privacy Practice Group. Ms. Compton-Brown focuses her practice on transactional and regulatory matters for a variety of providers in the healthcare industry.

Ms. Compton-Brown routinely counsels clients on scope of practice issues for licensed providers; contract drafting and negotiation; HIPAA compliance; physician and ancillary provider employment matters; physician-...

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