Follow-up consultation billing and documentation

Frequently, bills are not submitted for follow-up visits for patients who have been evaluated psychiatrically on medical-surgical services. There often is confusion regarding which procedure codes are most appropriate to use in billing. To help the consultant understand the documentation requirements for various procedure codes, information from several sources was synthesized and distilled. This paper should help minimize documentation errors and maximize reimbursement for clinical services. The authors have reviewed available billing choices, and clarified the documentation requirements for different procedure codes according to Medicare regulations.