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.

The UGA (Under General Anesthetic) modifier is intended to compensate physicians for the inconvenience of scrubbing in and preparing to do a procedure in the OR with the patient Under General Anesthetic when the procedure is ordinarily performed in a standard room without general anesthetic. Criteria:

• The UGA modifier is attached to procedures that may require an anesthetic and are paid less than the UGA modifier.

• It can be applied to a procedure when the conditions are such that the patient would not tolerate the procedure without the use of a general anesthetic and the physician must complete the service in the OR with the use of general anaesthetic.

• The UGA modifier does not apply to second and subsequent procedures done under the same anesthetic at the same operative encounter. Multiple procedures: The UGA modifier can be applied if more than one procedure is provided at the same encounter and only when each procedure is paid less than the rate of the UGA modifier. The physician may submit the UGA modifier on the procedure with the greater benefit rate. All other services provided at the same encounter will be paid at the rates listed in the Price List. All other payment modifiers will be applied as appropriate, e.g., LVP75, ADD, LVP50, etc.

When one or more of the procedures provided in the OR and under general anesthetic is paid equal or greater than the rate for the UGA modifier, the UGA modifier does not apply. It cannot be added to the service. The rates for each procedure will be applied according to the Price List.

For more information, please review Governing Rule 6.8.4