Wiki difference between refferal and consult - i am trying to find information

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sblanchard

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i am trying to find information about what is the differents between a refferal and a consult? can some one help me?

thank you
 
A referral is when a doctor sends a patient to you to take over care for a particular problem, or to take over the primary care duties.

A consult is when a doctor sends a patient to a specialist to evaluate that patient and issue a report back to the original doctor outlining a treatment plan. The care of the patient is not transferred.

There is more to it than this, but that is the basics.
 
the other big difference is that a consult is a service (and as such, billable) whereas a referral is not billable.

PS: Medicare no longer recognizes the consultation codes! 99241-99245 and 99251-99251. It won't be long before the others follow suit!

James
 
Jamesmmm said:
the other big difference is that a consult is a service (and as such, billable) whereas a referral is not billable.
James
Click to expand...

I feel this statement is somewhat misleading. Both services result in a billable charge once the patient is seen, it's just the code that's different.
 
hello W:
well look at it this way:
the referring physician does not bill for referring the patient but
the consulting physician does bill for his/her consultation

Hope this helps!

James
 
No matter whether it's a referral or a consult, the patient is seen by the doctor and then a charge is billed.

I am aware the the referring physician does not bill for referring the patient. That's not the point. The doctor receiving the patient DOES bill for seeing the patient. The difference is the code used. If it's a referral, the a New Patient E/M code is billed. If it's a consult, then those codes are used (unless it's Medicare, of course, but that's a different thread..).

I stand by my statement.
 
the original question asked what the difference between a consult and a referral is, and I thought it important to point out that for the most part, patients are not billed for referrals whereas patients do get bills for consults.

thanks.
 
Jamesmmm said:
the original question asked what the difference between a consult and a referral is, and I thought it important to point out that for the most part, patients are not billed for referrals whereas patients do get bills for consults.

thanks.
Click to expand...

Again I must disagree. The doctor sending the patient does not bill a charge for either service, but the receiving doctor bills the patient no matter whether it's a referral or a consult.

The difference between a referral and a consult has everything to do with Intent, Documentation, and CPT codes. It has nothing to do with who sends the bill.

Someone help me out here. Am I right or wrong?
 
The doctor sending the patient does not bill a charge

this is the referring physician

the doctor receiving the patient does bill

that is the consulting physician

I suppose you'd like to write this off to 'apples and oranges' but it's a point that should be made in any discussion of consults and referrals

Can anybody out there corroborate what I have been saying? Thanks alot.
 
Jamesmmm said:
I suppose you'd like to write this off to 'apples and oranges' but it's a point that should be made in any discussion of consults and referrals
Click to expand...

This is the part I have trouble with.

If you are a specialist and a doctor sends you a patient, you have to determine whether it's a referral or a consult. That is what the OP was asking about, how to tell the difference. The specialist receiving the patient is going to bill that patient for the service, no matter which one it turns out to be. By saying that a referral doesn't result in a charge to the patient is just plain wrong.

A discussion of the differences between a referral and a consult has nothing whatsoever to do with which one generates a charge. they BOTH generate a charge.
 
HTML: 
By saying that a referral doesn't result in a charge to the patient is just plain wrong.

I did not say the above, but since you mention it, the referral itself will never result in a charge- what happens after the referral is made by the referring physican to the consulting physician depends on whether or not the patient is evaluated and/or treated by the consulting physician.

A primary care physician might refer his/her patient to a cardiologist. But if the patient does not follow-up, then the "referral dosen't result in a charge to the patient"

Thanks again
 
Hi W: and since you also brought up specialists, perhaps we should have pointed out to the poster that specialists are more likely to do consults than are primary care physicians (pediatricians, internists and gynecologists) and that the PCPs are more likely to refer patients for specialist care. (Consults have higher RVUs than regular visits, which may account for Medicare eliminating them.)
 
True, but it's the same for a consult. If the doctor sends the patient to a specialist for a consult, but the patient doesn't keep the appointment, then the consult doesn't result in a charge to the patient either.

The differences we are discussing about charges to the patient are immaterial to question of whether an incoming patient to a specialist is a consult or a referral. The determining factors to differentiate between a referral and a consult are, and always have been:

1. The intent of the doctor that is sending the patient to the specialist
2. The documentaion in the medical record
3. The existance (or not) of a report from the specialist back to the original doctor

Saying that one generates a charge to the patient and one doesn't is wrong and immaterial to the discussion at hand. It does not help the specialist who is trying to decide which code to bill make his or her decision.
 
I completely agree with Walker....

Consultation-A consultation is a rendering of advice of a providers professional opinion, followed by a report of their findings to the requesting physician. The condition is undetermined or suspect...

Referral-The primary care does not expect to continue to treat the patient for the current condition (colitis) and refers the patient to a GI specialist (example) for treatment. The problem has already been identified and the PCP simply needs a specialist to provide on-going treatment. This is a transfer of care....

In either case both visits ARE billable. The specialist accepting the referral (transfer of care) certainly isn't going to provide this service for free...Nor would the consultant.
 
I agree with everything posted by Walker. He is 100% correct on all issues. I do not see this as an agree to disagree issue either. The physician that referrs the patient will have a charge for the visit where he evaluates the patient and decides to referr him for continued care to a different physician specialist or otherwise. His intent is to transfer over care hence it is a referral of care, he charges for his encounter and the receiving physician charges for his as a new or established patient. The physician requesting a consult charges for his visit when make the decision to ask another physician for an opinion and "consults" the other physician who will also charge for his visit as a consultation. Every gets to charge when they see the patient it is just a matter of what they charge.
 
Referral vs Consultation

I agree with Walker that whether the patient is referred for the care of the problem to be taken over or if the treating doctor requests a consultation - a bill is generated. If the patient has NO insurance, he/she will be responsible for either the referral OR the consultation fee (even though the consultation will be billed as a regular visit...no more consults).

In this wonderful world of freebies, medial treatment, for the most part, always comes with a price tag.
 
You are right....If a doctor see's a patient he's going to bill whether he send the patient for an opinion from another physician (consult) or he transfers care of the patient to another physician (referral). On the other end, the physician to whom the patient is sent is going to charge the appropriate E/M code for seeing the patient.

Michele R. Hayes, CPC, CPMA, CEMC, CGIC
 
I agree with Walker as well! Rebecca, well put! I'm an Auditor and would support the elimination of these codes across the board - simply becuase they are so misunderstood and abused. Just a note, please refer to the 2010 CPT books which expands on this a bit from previous years.
 
Consult vs referral

A Patient was refer by his primary care physician to Dermatoly doctor for a lesion. The primary care Physician put a note on the patient records that said Patient referral to Dermatology, he does not specify if he want the derm opinion about this lesion or if he is only doing a transfer of care. The Derm dr follow all the step for a consult and cc his finding to the requeting dr. Is this a consultation or a referral. In this case the requesting physician is not being clear on his notes. But the consultant is folling all the steps that will allow him to bill a consult, but because the requesting physician is not doing his part, the consultan can not bill a consult????? Help please:eek:
 
Referral

Mirlam09 ... this is EXACTLY why Medicare decided to stop recognizing consultation codes. Most providers - especially "specialists" - think any time they see a new patient it is a consultation.

The "referring" physician wants dermatology to take care of this problem (i.e. remove the lesion). The referring physician is NOT asking for the dermatologist to render advice or opnion on how the referring physician should take care of this.

No matter what the dermatologist calls it in his notes, this is a referral or transfer of care. The services should be coded as a new or existing patient (depending on whether any dermatologist in this same practice has seen the patient in the last 3 years).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
Last edited:
Tda ba,cpc

A referral is the complete transfer of care to another provider.

A consultation is a request from one provider to another provider for their medical evaluation, opinion, and/or advice of a specific problem(s) without the transfer of care; just asking for medical evaluation or opinion (e.g., a surgeon requesting pre-operative consultation for medical clearance prior to a surgery).

In order to bill consultation codes there must be a specific Request for the consultation from the requesting provider to the consulting provider. There must be a resultant Rendering opinion from the consulting provider. Then, there must be the Response back from the consulting provider to the requesting provider as to the results.

If a provider refers the patient to another provider, then that receiving provider will bill a new patient (as applicable) visit for the evaluation of that patient, not a consultation, since in this case there is a complete transfer of care, not a request for opinion.
 
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