Consultation Rules for Healthcare Providers

General Guidelines:

 

• Providers shall maintain documentation for each Cardholder receiving services, including:
  • Eligibility verification with photo ID.
  • Care rendered.
  • Billing records compliant with relevant laws, regulations, and standards.
• Providers shall maintain patient and physician signed copies of PULSE/ASOAP consent forms for every visit, including informed consents and acknowledgment of services rendered or products provided, signed by the insured.
• Providers shall maintain up-to-date medical records, signed receipts, bills, and invoices for all rendered services, including but not limited to:
  • Consultations
  • Prescriptions
  • Procedures
  • Physiotherapy
  • Laboratory and radiology services
  • Inpatient and day care services
• Providers shall maintain documentation of patient education and discharge instructions when applicable.
• Providers shall maintain patient share invoices, signed by the patient.
• Ensure accurate time documentation for CPT codes where required, such as physiotherapy modalities, IV infusions, OT, and anesthesia units.
• Shall not misrepresent or inflate treatment charges, including unbundling, upcoding, or splitting of charges/services.
• All records or other relevant documents shall be provided to Nextcare when requested. If not available, the service will be considered as not rendered.

 

Emergency Consultations:

 

• All consultations done in the emergency department/room should be billed under DSL code 61.08 and not under DSL 9, 10, or 11.

 

Subsequent Consultations:

 

• Subsequent consultations within the 2nd, 3rd, and 4th weeks from the initial consultation for the same illness should be billed under:
  • 9.02
  • 10.02
  • 11.02

 

Consultation for Prescription Refill:

 

• Prescription refills without face-to-face consultations should be billed as DSL 13.

 

Psychiatric Consultation:

 

• Psychiatrist consultations should be billed under:
  • DSL 61.11 for adults
  • DSL 61.12 for children
    Psychiatric consultations should not be billed under DSL 10 or 11.
• Psychiatric consultations billed under DSL 61.11 and 61.12 cannot be billed with CPT codes 90791 and 90792, as per CPT coding guidelines.

 

Consultation Rules for Dental Providers

 

• Providers should bill CDT codes for consultations as per their descriptions. For example:
  • Comprehensive Consultation (D0150) should not be billed when Limited Consultation (D0140) is performed.
• Dental consultations should be billed once every 3 months.

 

Billing of Follow-up Consultations:

 

• Follow-up visits within 7 calendar days are free for the same condition when seen by the same medical practitioner within the applicable network. The day of the initial visit is counted as day 1.
• Multiple consultations with the same doctor at the same provider on the same day, regardless of the timing or encounter type, will be considered a follow-up consultation and should not be billed.
• Repeat consultation codes are to be billed for visits during the 2nd, 3rd, and 4th weeks following the initial consultation.

 

Tele-Consultation Rules:

 

1. Teleconsultation services require pre-approval and are limited to one consultation per week for the same specialty.
2. Follow-up teleconsultations within 7 days at the same provider are free, starting from the date of the initial teleconsultation until the end of the 7th day (midnight), following the same protocols as regular follow-up consultations.
3. Any in-person consultations within 7 days of the teleconsultation should not be billed, as the teleconsultation will be considered free.
4. Policy exclusions, limits, sub-limits, or general exclusions will apply, and teleconsultations for non-covered conditions will be rejected.
5. Internal teleconsultation referrals from one specialty to another shall be billed as a single teleconsultation.

 

 

Dubai Consultation Rules:

 

• Consultations and follow-up consultations do not require pre-approval.
• All dental consultations require pre-approval.
• Follow-up consultations are free of charge for the first 7 days following the initial consultation, with the day of the first visit counted as day 1.
• In cases of in-patient admissions, no out-patient or emergency encounters should be submitted on the same day.
• For chemotherapy billed as DRG, outpatient consultations should not be billed separately on the same day.
• Only DSL codes shall be used for consultations; E&M codes should not be used.
• Dental consultations should not be billed when a procedure is performed.
• Members in the PCP Network are required to have a Primary Care Physician (General Practitioner – GP) referral for any specialist consultation or inpatient treatment.
• If a GP refers a patient to a specialist within the same group facility, GP charges will be waived and are not billable.
• For ENAYA members only: code 92015 is covered for members up to the age of 14 years in clinics and optical shops. Beyond the age of 14, it is only covered at optical shops.

 

Code	Description	Detailed Description
11	Consultation Consultant	Office consultation by a Consultant Physician For the evaluation and management of a new or established patient which includes, at a minimum, a problem focused history, problem focused examination and straightforward medical decision making.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
10.02	Consultation Specialist – Repeat	Specialist repeat visit for OP Consultation refers to week 2, 3 & 4 from the date of initial consultation for same illness in OPD.
10	Consultation Specialist	Office consultation by a Specialist Physician For the evaluation and management of a new or established patient which includes, at a minimum, a problem focused history, problem focused examination and straightforward medical decision making.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
10.01	Consultation Specialist	Free follow-up consultation of the same diagnosis within 7 days of initial consultation by a Specialist.
9.02	Consultation GP – Repeat	GP repeat visit for OP Consultation refers to week 2, 3 & 4 from the date of initial consultation for same illness in OPD.
9.01	Consultation GP	Free follow-up consultation of the same diagnosis within 7 days of initial consultation by a General Practitioner.
9	Consultation GP	Office consultation by a General Physician For the evaluation and management of a new or established patient which includes, at a minimum, a problem focused history, problem focused examination and straightforward medical decision making.  Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs.
11.02	Consultation Consultant – Repeat	Consultant repeat visit for OP Consultation refers to week 2, 3 & 4 from the date of initial consultation for same illness in OPD.
13	PRESCRIPTION W/O CONSULTATION	Repeat Prescription issued without face to face consultation
61.08	Emergency Consultation	Consultation by a physician at Emergency Room

 

 

Abu Dhabi Consultation Rules:

 

The following CPT-4 codes for Evaluation and Management (E&M) services are not separately reimbursable if billed for the same patient, within the same specialty, at the same facility or facility group on the same date—or within the subsequent week of service. In such cases, reimbursement will be made only for the higher-paying code among the codes billed for the following combinations:

1. New patient, office, or other outpatient visit billed along with another new patient, office, or other outpatient visit.
2. Established patient, office outpatient visit occurring within 7 days from the initial new or established patient, office, or other outpatient visit.
3. New or established patient, subsequent hospital care billed along with a new or established patient initial inpatient consultation (applicable only for the same date of service).
4. New or established patient, initial hospital care billed along with a new or established patient subsequent hospital care (applicable only for the same date of service).
5. The calculation of the “Follow-up within one week” starts from and includes the day of the initial visit (Activity Start) and should be billed using E&M codes for established patient visits (codes 99211 to 99215) at a “0” value.

 

The Evaluation and Management (E&M) services in outpatient settings will be reimbursed as per the below guidance effective 15th of October 2024:

The actual coding for outpatient services of the E&M levels shall be based on the coding guidelines, the documentation requirements, and the updated DOH Coding Manual; noting that the said actual coding is mandatory to meet the documentation audit requirements of Tasneef..

 

Reimbursement of outpatient E&Ms will follow the below criteria:

1. Reimbursement of General Practitioners consultations will be capped to level 2 E&Ms & coding documentation requirements apply.

 

Reimbursement of General Practitioners privileged in family medicine, psychiatry, Obstetrics & Gynecology, will be capped up to level 3 E&Ms & coding documentation requirements apply.

 

2. Reimbursement of specialists’ consultations will be capped up to Level 3 E&Ms & coding documentation requirements apply.

 

• Both the actual E&M and the billed E&M should be reported on the claims (similar to the existing process adopted for new facilities).
• These rules do not apply to emergency E&Ms and Preventive E&Ms.
• The above rules does not apply to consultants.

 

Modifier 52: Reduced Services

 

It is intended to be used in Abu Dhabi when billing E&M CPT codes for follow up E&M visits occurring between day 8 to 14 of the initial E&M visit. The first E&M visit during this period will be paid at 50% of the contractual price. Any subsequent E&M visit during the same period will be paid at “0” value.

 

1. This rule is applicable to all E&M visits for the same patient, for the same specialty at the same facility or the same facility group.
2. In case the patient visits a clinician of different specialty but with privileges for the specialty of initial E&M visit, this shall be adjudicated as a subsequent E&M visit to a physician of same specialty.
3. Modifier 52 must be reported as an observation field to E&M CPT codes as defined in Routine

 

Reporting requirements published at www.doh.gov.ae/shafafiya/reporting to be eligible for the 50% reimbursement.

Below groups and conditions are excluded from the applications of day 8 to 14 day follow up rules:

• E&M visits for pediatric patients under 18 years.
• E&M visits for senior patients above 60years.
• E&M visits for People of Determination.
• E&M visits related or following IFHAS, other preventive screenings, and vaccination services
• E&M visit for Psychiatric conditions as performed by Psychiatrist only.
• E&M visit for Pregnancy and Maternity related conditions.
• Emergency E&M visits

 

Modifier 24 : Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period.

 

Modifier 24 may be used for 100% reimbursement of unrelated E&M visits provided for the same patient, for the same specialty, at the same facility or the same facility group occurring within day 1 to 14 follow up period.

The following are eligible for a 100% E&M payment while occurring within day 1 to 14 follow up period:

 

• The subsequent E&M visit cannot be reasonably related or detected as part of the initial E&M visit, documentation of evidence and justification should be provided to avail reimbursement.
• Referral to a subspecialist consultant in the same specialty for a second opinion (99241 – 99245).
• E&M visits occurring within day 8 to 14 follow up period of an initial Emergency E&M visit.

 

Modifier 24 must be reported as an observation field to E&M CPT code as defined in Routine Reporting requirements published at www.doh.gov.ae/shafafiya/reporting to be eligible for 100% reimbursement.

 

Modifier 25: Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service

 

 

• E&M services rendered on the same date of service by the same facility, same clinician as that of a minor procedure, for the same principle diagnosis / chief complaint shall not be reimbursed separately. However:

• A significant and separately identifiable E&M service unrelated to the decision to perform the minor procedure shall be separately reimbursable by reporting the E&M service with Modifier 25 if provided by the same physician on the same day as the minor procedure or service.
• The physician must appropriately and sufficiently document both the E&M service and the minor procedure in the patient’s medical record to support the claim for these services.
• Modifier 25 shall only be appended to E&M services and may be applicable with multiple E&M services.
• Modifier 25 shall be reported as an observation field as defined in Routine Reporting requirements published at www.doh.gov.ae/shafafiya/reporting.

 

 Modifier 25 is applicable with the procedures listed in “modifier 25 relevant CPTs” sheet in the Routine reporting requirements published at www.doh.gov.ae/shafafiya/reporting.

 

 

Northern Emirates:

 

1. For Northern Emirates IP claims, consultation by the treating physician/surgeon on the day of the surgery is not billable.