Wiki Consults

[KoBee]

I still get a bit confused on Consults vs Referral.

I think our providers get confused themselves, I find myself at times trying to find the easiest way to explain the difference.

If the consulting provider puts an order for the patient to come back and see them, that is not help constitute a consultation code CPT 99242-45, correct? If consulting provider would want the patient to return, shouldn't the consulting provider report this back to the requesting physician and let the requesting physician put in a new order as a referral this time back to the consulting provider?

Help :/

Example:
PCP (requesting) order to see patient Ped gastro
Ped gastro (consulting) sees patient and treats with diagnostic test/labs, request patient to come back and see them by putting an order (authorization w/payer) to see them again.

 

[CBLENNIE]

The following long description from Encoder Pro may help you clear this up for yourself and your providers.

Office or other outpatient consultation service codes describe encounters where another qualified clinician's advice or opinion regarding diagnosis and treatment is rendered at the request of the primary treating provider. Consultations may also be requested by another appropriate source (e.g., a third-party payer may request a second opinion). The request for a consultation must be documented in the medical record, as well as a written report of the consultation findings. During the course of a consultation, diagnostic or therapeutic services may be initiated at the same encounter or at a follow-up visit.​

The important things to remember with consults are the 3 Rs:

• Request from the treating provider (or a 3rd party such as an insurance company)
• Reason the requesting provider must state a specific reason for the consult
• Report from the consulting provider needs to be written with the consultant's opinion and the report needs to be sent back to the requesting provider.

Another tip to remember is that if the patient and/or family requested the consult you cannot bill with a consult CPT code 99242-245.

Here is a help, if a bit old, AAPC blog post link regarding billing for consults Remember the 3 Rs for Payers Accepting Consults.

I hope this helps clear things up for you and your providers.

 

[csperoni]

For years, consultation codes were misunderstood, overused, and abused. I believe a large portion of this is simply because what a clinician calls a consult is NOT the coding definition of consult.
In your example, what seems to be missing is a report from the peds GI back to PCP.
Don't forget many payors have followed Medicare's policy and no longer recognize consult codes. I think we are down to just 2 payors that will accept them. We were getting so many denials that we don't even bother using consult codes anymore. It's more work for the coder to ensure the 3 Rs are met, then also check if the carrier accepts them.