QUEST Integration - Office Consultations and Visits

Original Effective Date:
08/01/1994
Current Effective Date:
01/01/2015

HMSA’s Plan for QUEST Integration Members covers office consultations and evaluation and management (E/M) visits according to the following definitions:

Office Consultation

An office consultation is a service rendered by a physician whose opinion or advice regarding a specific problem or condition is sought by the patient’s PCP. The PCP continues to manage the patient’s care after the consultation. The consulting physician may recommend or initiate diagnostic and/or therapeutic services. The consulting physician’s report must be forwarded to the PCP and documented in the patient’s medical record.

Please note that the following are not considered office consultations:

• Pre-determined transfer of care from one physician to another. If a physician refers a patient to another physician in a different specialty or subspecialty for evaluation and treatment of a condition, this service is a referral and should be billed by the referred physician as a new or established patient visit as appropriate.
• Services requested by a patient (self-referral). Services requested by the patient and/or the patient’s family and not by another physician should be billed as a new or established patient visit as appropriate.

Note: QUEST Integration patients must be referred by their PCP for all care by specialty providers. Services rendered without PCP referral are not payable.

• Follow-up consultations. These services should be reported as established patient visits if initiated by the physician consultant or the patient.

Note: QUEST Integration patients must be referred by their PCP for all care by specialty providers. Services rendered without PCP referral are not payable.

• Consultations required by hospital rules and regulations
• Anesthesia consultations
• Telephone consultations
• Radiological (except for therapeutic services) or pathological consultations
• Consultation within the same specialty or subspecialty

Medical Visit

New patient

A member is considered to be a new patient when the patient has not been seen before by the physician, or the patient has not been seen within the past three years by the physician.

For physicians in a group or clinic practice, the patient also has not been seen by another physician of the same speciality in the same group or clinic.

Established patient

A visit is considered to be an established patient’s when the patient’s medical history is familiar to the physician and the patient has been treated by the physician within the three years of the visit.

Note: When a physician is covering for another physician who is in the same practice or clinic, the visit is not considered a new patient visit and payment is based on the eligible charge for an established patient visit.

In addition, a new patient visit should not be billed when a physician changes the location of his or her practice. As long as the physician has treated the patient within the past three years, the patient is considered an established patient regardless of the location where the patient is being treated.

Multiple Visits on the Same Day

QUEST Integration generally covers only one professional visit each day per provider per patient. When more than one visit is billed, the code with the higher payment normally is paid. More than one visit per day may be paid to a provider for critically ill patients and acute surgical problems. Documentation to support the additional visit on the same day must be submitted with the claim.

Claims Filing Information

When billing for an initial office consultation, indicate the “referred from” provider (last name, first name, middle initial) in Block 17A. As needed, HMSA may request consultation reports or supporting documentation from physicians.

Revision History