Fee Navigator®

    Governing Rule: 6.6


    • 6.6.1

      If a patient is admitted to a hospital for the purpose of undergoing a procedure designated "+", a benefit is payable for a visit provided the day before or the day after the procedure is performed, but if the procedure is performed and a visit occurs on the same day, a benefit is payable for either the procedure or the visit, but not both.

    • 6.6.2

      If a procedure designated "+" is performed in a physician's office, both the procedural benefit and the appropriate office visit benefit for that day may be claimed, but if a consultation benefit pursuant to GR 6.6.4 has been claimed, a visit benefit will not be payable for the day on which the procedure is performed.

    • 6.6.3

      If a procedure designated "+" is performed in a place other than a physician's office, either a procedural benefit or a visit benefit, but not both, may be claimed for that day.

    • 6.6.4

      If a procedure designated "+" and a consultation are provided on the same day, both the procedural benefit and the appropriate consultation benefit are payable.

    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.