ED Coding and Reimbursement Alert

Question: It is my understanding that if a requesting physician asks for an opinion about a condition and the consulting physician sends the patient back to the requesting physician for treatment, this constitutes a -consultation.- I also thought a -referral- is when a patient's care for a condition is transferred from one physician to another. The 2007 CPT book states that -A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.- Also, the CPT book does not define -referral.- Which definitions are correct? Oklahoma Subscriber
Answer: The Centers for Medicare and Medicaid Services updated Medicare rules for consultations on Jan. 1, 2006. The AMA then clarified its opinion on what qualifies as a consultation in the 2007 CPT manual issued in late November. The 2007 CPT has tried to clarify the AMA position as opposed to the very stringent position of CMS. You can download Medicare's updated consultation rules to the Medicare Carriers Manual Chapter 12, section 30.6.10 from cms.hhs.gov/transmittals/downloads/R788CP.pdf (changes appear in red). Bottom line: Apply the CMS rules for government payers, and apply the AMA rules for private payers.
Reader Questions and You Be the Coder reviewed by Michael A. Granovsky, MD, CPC, FACEP, president of MRSI, an ED coding and billing company in Woburn, Mass.