405 IAC 5-8-3 - Restrictions

Current through December 29, 2021

Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2

Affected: IC 12-13-7-3; IC 12-15

Sec. 3.

(a) A consultation cannot be used for the evaluation of a nonphysician referred or self-referred member.
(b) An office or other outpatient consultation must address a specific condition not previously diagnosed or managed by the consulting physician. If an additional request for an opinion or advice regarding the same or a new problem is received from the attending physician and documented in the medical record, the office consultation codes may be used by the consulting physician again.
(c) Reimbursement for an initial consultation is limited to one (1) per consultant, per member, per inpatient hospital or nursing facility admission.
(d) Follow-up inpatient consultations may be billed if visits are needed to complete the initial consultation, or if subsequent consultative visits are requested by the attending physician. These consultative visits include monitoring progress, recommending management modifications, or advising on a new plan of care in response to changes in the patient's status.
(e) Reimbursement is not available If a member is referred for management of a condition or the consulting physician assumes patient management.

Notes

405 IAC 5-8-3
Office of the Secretary of Family and Social Services; 405 IAC 5-8-3; filed Jul 25, 1997, 4:00 p.m.: 20 IR 3310; readopted filed Jun 27, 2001, 9:40 a.m.: 24 IR 3822; filed Oct 3, 2001, 9:47 a.m.: 25 IR 379; readopted filed Sep 19, 2007, 12:16p.m.: 20071010-IR-405070311RFA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA Errata filed 11/1/2016, 9:36 a.m.: 20161109-IR-405160493ACA

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