§ 1150.56a. Payment policy for consultations—statement of policy.
(a) The Department pays for five levels of inpatient and outpatient consultations. Payment for inpatient consultations is limited to two consultations per hospitalization. The definition of each level is set forth in subsection (b).
(1) A referral to another practitioner does not constitute a consultation. When a patient is referred to another practitioner, the medical record shall indicate the name of the practitioner and the reason for the referral. When a physician transfers the total responsibility for care of the patient to another practitioner, the physician accepting the patient may bill for medical care or surgical procedures. This transfer of responsibility shall be noted in the patient’s medical record.
(2) Payment will not be made for a self-referred consultation. A consultation shall be requested by another practitioner.
(3) Payment will not be made for a consultation when it is performed by a surgeon or assistant surgeon regarding the advisability of definitive surgery and surgery is subsequently performed by that surgeon or assistant surgeon. This is not applicable to second opinions mandated by the Department’s Second Opinion Program.
(4) Payment will be made for a consultation provided by a surgeon regarding the advisability of definitive surgery when subsequent surgery is not performed.
(5) Payment will not be made for a consultation when it is performed by the same physician or assistant who performs the obstetrical delivery.
(6) Payment will not be made for a consultation provided by an anesthesiologist prior to surgery. This is considered to be a pre-operative work-up and the fee for anesthesia services includes payment for the pre-operative work-up.
(7) Payment will be made for a consultation provided by an anesthesiologist if the consultation results in a decision not to administer anesthesia during the hospitalization.
(8) Payment for an inpatient consultation includes follow-up care; therefore, the consultant is not eligible to bill for daily medical care. Only the attending physician is entitled to bill for daily medical care.
(9) Payment will not be made for consultations which are performed solely to meet a hospital requirement.
(b) The following definitions and procedure codes are provided for clarification of the terms used in conjunction with consultations:
(1) Limited Consultation (90600)—The physician confines his service to the examination or evaluation of a single organ system. This procedure includes documentation of the complaints, present illness, pertinent examination, review of medical data and establishment of a plan of management relating to the specific problem. An example would be a dermatological opinion about an uncomplicated skin lesion.
(2) Intermediate Consultation (90605)—An examination or evaluation of an organ system, a partial review of the general history, recommendations and preparation of a report. An example would be the evaluation of the abdomen for possible surgery that does not proceed to surgery.
(3) Extended Consultation (90610)—The evaluation of problems that do not require a comprehensive evaluation of the patient as a whole. This procedure includes the documentation of a history of the chief complaints, past medical history and pertinent physician examination, review and evaluation of the past medical data, establishment of a plan of investigative or therapeutic management and the preparation of an appropriate report. For example: The examination of a cardiac patient who needs assessment before undergoing a major surgical procedure or general anesthesia.
(4) Comprehensive Consultation (90620)—An indepth evaluation of a patient with a problem requiring the development and documentation of medical data (the chief complaints, present illness, family history, past medical history, personal history, system review and physical examination, review of diagnostic tests and procedures that have previously been done), the establishment or verification of a plan for further investigative or therapeutic management and the preparation of a report. For example: A young person with fever, arthritis and anemia; or a comprehensive psychiatric consultation that may include a detailed present illness history, and past history, a mental status examination, exchange of information with primary physician or nursing personnel or family members and other informants, and preparation of a report with recommendations.
(5) Complex Consultation (90630)—An uncommonly performed service that involves an indepth evaluation of a critical problem that requires unusual knowledge, skill, and judgment on the part of the consulting physician, and the preparation of an appropriate report. An example would be acute myocardial infarction with major complications. Another example would be a young psychotic adult unresponsive to extensive treatment efforts under consideration for residential care.
(6) Attending practitioner—The practitioner of record who is primarily responsible for the total care and treatment and retains overall responsibility for coordination of the care of the patient.
(7) Referral—The transfer of the total or specific care of a patient from one practitioner to another which does not constitute a consultation.
(c) Claims submitted for payments are subject to utilization review.
Source The provisions of this § 1150.56a adopted April 20, 1990, effective April 21, 1990, 20 Pa.B. 2199.
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