Ophthalmology and Optometry Coding Alert

Question: Past Ophthalmology Coding Alert articles contain definitions that differ from CPT. An article states 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 that this constitutes a -consultation.- A -referral- is when one physician transfers a patient's care for a condition to another, according to the article.

The CPT manual 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 manual does not define -referral.- Which definitions are correct?


Oklahoma Subscriber

 
Answer: The article describes the Medicare rules for consultations, which CMS updated Jan. 1, 2006. The AMA clarified its opinion on what qualifies as a consultation in the 2007 CPT manual issued in late November. That information was not available at the time of composing the article you reference -- only the Medicare rules and the old AMA text were available.

CPT 2007 tries to clarify the AMA position as opposed to CMS- very stringent position. You can download Medicare's updated consultation rules from the Medicare Carriers Manual Chapter 12, section 30.6.10, as discussed in the article from www.cms.hhs.gov/transmittals/downloads/R788CP.pdf (changes appear in red).