Office Visits and Consultations

HMSA benefit payments are made for evaluation and management (E/M) visits and office consultations according to the following definitions:

Medical Office 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.

Established patient

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

Notes: 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.

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 another physician. The physician requesting the consultation generally continues to manage the patient’s care following the consultation. The consulting physician may recommend or initiate diagnostic and/or therapeutic services. The consulting physician’s report must be forwarded to the requesting physician and documented in the medical record.

Please note that the following are not considered office consultations:

• Predetermined transfer of patient 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 requested by another physician should be billed as a new or established patient visit as appropriate.
• Follow-up consultations. These services should be reported as established patient visits (CPT 99211-99215) if initiated by the physician consultant or the patient.
• 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.

Claims Filing Information

When billing for an initial office consultation, indicate the “referred from” provider (last name, first name, middle initial) in block 17 of the CMS 1500 claim form. As needed, HMSA may request consultation reports or supporting documentation from physicians.

Office Visits - Use of Modifiers

Revision History