Optometry Coding & Billing Alert
Observe Different CMS, CPT Consult Criteria
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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/therapeutic services at the same or subsequent visit." Also, the CPT book does not define "referral." Which definitions are correct? Oklahoma 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.
Optometry Coding & Billing Alert
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