Internal Medicine Coding Alert
Remember Differences in CMS, CPT Consult Criteria
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Question:
The 2007 CPT book states, "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?
Tennessee Subscriber
Answer: CMS 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 http://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.
-- Answers to
You Be the Coder and Reader Questions were reviewed by Bruce Rappoport, MD, CPC, CHCC, a board-certified internist and medical director of Broward Health's Best Choice Plus and Total Claims Administration in Fort Lauderdale, Fla.Internal Medicine Coding Alert
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Remember Differences in CMS, CPT Consult Criteria
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