Correctly Code for Consults, Referrals and Transfers of Care

Infectious disease specialists often see patients sent by other physicians, and each time they have to decide whether the visit is a consultation or a referral. This can be confusing unless you are aware of the requirements for coding a consultation.

For example, when an orthopedist suspects a patient has bone disease (osteomyelitis, 730.2) and sends the patient to an infectious disease (ID) specialist to confirm the diagnosis, is that a consult or a referral? Consider this a consult if these three criteria are met:

1. The patients record contains documentation of a written or verbal request to the ID specialist for the care from the patients physician or other healthcare provider, such as a nurse practitioner or physicians assistant.

2. The initial physician requests another physicians opinion or advice regarding evaluation and/or management of a specific problem.

3. The receiving physician communicates in writing the results of the consultation.

If any of the three are not met, then the service cannot be considered a consult and must be considered a referral, says Jean Stoner, CPC, manager of coding operations at CodeRyte Inc. in Bethesda, Md. If a referring provider has diagnosed a condition but does not want to manage it and sends the patient to a specialist, this is considered a referral and not a consult.

The essence of a consultation is to get an opinion, agrees Sharron Stevens, CPC, coding and reimbursement specialist for Eastern Tennessee College of Medicine. The responsibility for care stays with the physician requesting the consultation. When the responsibility for care changes, then it is a referral situation and not a consultation.

The Fine Points Of a Consultation

More difficult to code would be the case when, for example, the orthopedist sends the patient to the ID specialist with instructions to confirm the diagnosis and to treat the patient. Gunner Deery, MD, an ID specialist at Northern Michigan Hospital in Petoskey, Mich., says he would code this as a consultation (99241-99245) as long as the ID specialist sends a report back to the sending physician. But Deery, past president of the Michigan Infectious Disease Society, says that any subsequent visits by the patient would have to be coded as an established patient office visit (99211-99215).

Stoner agrees, saying this patients first visit to the ID specialist most likely can be coded as a consult because the orthopedist isnt sure the patient has osteomyelitis and needs the ID specialists opinion to confirm the diagnosis.

An example of a referral might be a patient with HIV or AIDS who is sent to an ID specialist with the intent for the specialist to become the patients primary-care physician (PCP). Deery would consider that a referral of [...]

- Published on 2000-04-01