Urology Coding Alert

Question: Past Urology Coding Alert articles contain definitions that differ from CPT Codes . An article states that if a requesting physician asks for an opinion about a condition and the consulting physician then sends the patient back to the primary physician for treatment that this constitutes a "consultation." A "referral" is when a patient's care for a condition is transferred from one physician to another, according to the article.
 
The 2006 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 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 this story -- only the Medicare rules and the old AMA text were available.

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 as discussed in the article from www.cms.hhs.gov/transmittals/downloads/R788CP.pdf (changes appear in red).

Bottom line: Apply the CMS rules for government payers, but apply the AMA rules for private payers.