Wiki Consult vs Referral

[KoBee]

Hello,

This has a been hot topic recently in our office and I have noticed we are having trouble with providers understanding the difference of a consult and referral.

In our system, when a requesting physician is putting an order/request for patient to see a specialist, they have the option to enter " consult only" or " referral ". Noticed when they put " consult only", the consultation provider's treatment/assessment plans mostly state to have the patient follow up with them in 2 weeks, 1 month or 4 months for results of any diagnostic test/labs that were requested.

Is it safe to say, if consulting provider is following with patient in 2 weeks or 1 month, that is not a consult CPT 99242-45?

if requesting physician doesn't have a diagnosis established and needs a specialist (consulting) to check out patient in how they can help treat, isn't that a consult?
if requesting physician does have a diagnosis already established and has tried treatment to help but is not helping, needs a specialist (consulting) to check out patient and continue to treat the established diagnosis, isn't that a referral?



Greatly appreciate any feedback in how we can help our staff and providers understand the difference.

 

[lgardner]

your thinking seems spot on, to me.

per American College of Rheumatology:
" A consultation is a request by a qualified provider for the advice or opinion of a physician regarding the evaluation and/or management of a specific problem. A referral is the transfer of care from one physician to a second physician when the second takes over responsibility for treatment of the patient."

per American Academy of Family Practitioners:
"
A consultation is a request from one physician to another for an advisory opinion. The consultanting physician performs the requested service and makes written recommendations regarding diagnosis and treatment to the requesting physician. The requesting physician utilizes the consultant’s opinion combined with professional judgment and other considerations (e.g., patient preferences, other consultations, family concerns, and comorbidities) to provide treatment for the patient.

A referral is a request from one physician to another to assume responsibility for management of one or more of a patient’s specific conditions. This represents a temporary or partial transfer of care to another physician for a specific time until resolved, or on an ongoing basis. It is the responsibility of the physician accepting the referral to maintain appropriate and timely communication with the referring physician and to seek approval from the referring physician for treating or referring the patient for any other condition that is not part of the original referral."

 

[KoBee]

your thinking seems spot on, to me.

per American College of Rheumatology:
" A consultation is a request by a qualified provider for the advice or opinion of a physician regarding the evaluation and/or management of a specific problem. A referral is the transfer of care from one physician to a second physician when the second takes over responsibility for treatment of the patient."

per American Academy of Family Practitioners:
"
A consultation is a request from one physician to another for an advisory opinion. The consultanting physician performs the requested service and makes written recommendations regarding diagnosis and treatment to the requesting physician. The requesting physician utilizes the consultant’s opinion combined with professional judgment and other considerations (e.g., patient preferences, other consultations, family concerns, and comorbidities) to provide treatment for the patient.

A referral is a request from one physician to another to assume responsibility for management of one or more of a patient’s specific conditions. This represents a temporary or partial transfer of care to another physician for a specific time until resolved, or on an ongoing basis. It is the responsibility of the physician accepting the referral to maintain appropriate and timely communication with the referring physician and to seek approval from the referring physician for treating or referring the patient for any other condition that is not part of the original referral."

Thank you for the information-

Just one quick question, I have a concern with the letter (report back) to the requesting physician.

In our practice we have a
- Request (order) from requesting physician
- Reason for the request is in the order
- Services rendered by consultant (chart note), which consultant also documents in the chart note, who is the requested physician and why.
- Letter from consultant to requesting physician with findings/recommendations

But majority of our providers are not really using the letter, which would be the report back to the requesting physician, I read: The consultant physician should provide a written report of services provided, findings and recommendations or planned follow-up. Where the requesting physician and consultant physician share a common patient record, this documentation can be included in the patient's progress notes.

Would this eliminate the letter then?

the progress note (chart note) for the DOS, in the assessment/plan is what i think is the reporting of the findings and recommendations and any follow up or not?

 

[lgardner]

yes. the "thank you" letter (as we called it in my practice) is a requirement of a consult.

I am not sure of the legality of documenting that in the patient records, instead of a "letter".
I have read that for inpatient, documenting in the progress notes is okay.

But, even for Medicare (which doesn't accept consult codes), we required the letter before billing the E/M.
I consider it more of a patient care issue.