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CMS Updates Guidance for Coverage of Interprofessional Consultation

A new letter from the Centers for Medicare & Medicaid Services (CMS) to state health officials clarified that Medicaid and Children’s Health Insurance Program coverage and payment for interprofessional consultation is permissible, even when the beneficiary is not present, as long as the consultation is for the beneficiary’s direct benefit.

Interprofessional consultation occurs when a patient’s health care provider, or treating practitioner, requests guidance from a health care provider with specific specialty expertise, or consulting practitioner without face-to-face contact between the patient and the consulting practitioner. This guidance supersedes CMS’ 2018 policy that prohibited coverage and payment of interprofessional consultation as a distinct service, because direct coverage for specialty consultation services required the patient’s presence.

Interprofessional consultations may be paid for under existing mandatory and optional state plan benefits, such as physician services, services of other licensed practitioners, rehabilitative services, and health homes. If states choose to pay for these services, they must submit a State Plan Amendment to add a payment methodology for the qualifying interprofessional consultation service.

By allowing direct payment to consulting practitioners, CMS hopes to expand and expedite access to specialty care and reduce the administrative burden to treating practitioners.

Contact Senior Director of Policy Erin O’Malley at eomalley@essentialhospitals.org or 202.585.0127 with questions.

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About the Author

Faridat Animashaun is a policy associate at America's Essential Hospitals.

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