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Medicare Consultation Requirements

As of Jan. 1, 2010, Medicare changed its payment guidelines on how billing can be presented for a consultant. While previously any doctor could present a consultation billing after being asked to give a medical opinion, consultations after this date must meet more stringent guidelines. The key for patients now needing a consultation is to make sure both doctors properly document their files before billing Medicare, in hopes of consideration for payment.

  1. Documentation Requirements

    • A written request for a consultation must be documented in the medical records by the requesting medical provider, and be noted in the consultant's medical record; and it must clearly show why the consultation is needed. If the request is made verbally, written documentation is still required to show the reason for the request; and again, it must be noted in both providers' records. The consultant's final written report is required to show the findings, as well as explain the recommendations for the patient.

    Preoperative Issues

    • Any preoperative consultation required at the request of a surgeon is allowable by Medicare, as long as the service is considered medically necessary. After consultation, if the same provider is managing all or part of the patient's post-operative care, all follow-up visits must be billed.

    Postoperative Issues

    • After surgery, a provider can be asked to see the patient and manage some of his or her postoperative care. However, this care cannot be billed as a consultation to Medicare, because the provider did not see the patient prior to surgery. Rather, it must be billed as hospital care subsequent to the surgery.

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