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Consult or Referral

  1. #1
    Default Consult or Referral
    Medical Coding Books
    If the documentation says "Patient referred by Dr. Jones." can this still be billed as a consult?

    We have done a lot of work educating our docs on losing the Refer and documenting Consult, but a few of our older physicians don't see the difference. Does it really matter if they use the word 'refer' rather than 'consult'?

    Thanks for your help. You guys are so smart!


  2. #2
    Duluth, Minnesota
    does the doctor providing the consult (via the referral), meet the requirements for billing/coding a consult?
    Is it clear who REQUESTED the patient be seen by them and why?
    does the provider RENDER his decision based on the exam performed?
    does the provider send the REPORT of their findings back to the referring provider?

    OR, does your doctor take over care per the request of the other provider. (because the issue is out of their area of expertise)
    Donna, CPC, CPC-H

  3. #3
    North Carolina
    It's hard to say w/o more information.

    I look for this type of documentation:

    " Patient here for consultation ...."
    "Consulting services requested."

    Patient has been referred by..."

    But of course...the intent and the documentation is critical

  4. #4
    Default Vague documentation
    That's my problem. The documentation is not clear.

    He treats the problem, prescribes medication and scheduled a follow-up in one month to re-assess the problem, which sounds like a referral.

    But he sends a report back to the physician that sent the patient to his practice.

  5. #5
    I wouldn't code a consult then, just a new patient e/m

  6. #6
    North Carolina
    I would query the physician. As for the report he's sending back...many of my providers send a letter to the PCP or whoever referred the patient. They do this so that the provider(s) are aware of how the patient's condition(s) are being managed. I just had a heart to heart meeting with one of my physicians. The statement "refer"/"consult" was a matter of somantics for him. I really had to help him understand the difference as well as providing "visual examples". I had to keep reiterating the 3 R's and the intent of the visit. I find that I have to find a creative approach for many of my providers.

  7. #7
    Duluth, Minnesota
    my vote is still for a consult actually...
    however, I think talking to the provider for clarification, the 3-R's and the intent of the visit are a great way to help determine clearly what the visit was. (as rebecca pointed out)

    Donna, CPC, CPC-H

  8. #8
    Milwaukee WI
    Default Intent of the original physician
    Whether it's a consultation or a transfer of care is really best determined by the intent of the physician who sent the patient to you.

    The best and easiest way to determine this is to have a form sent to the originating physician asking specifically whether this is a consultation (and for what problem), or whether this is a request to treat a problem.

    Sometimes the nature of YOUR specialty helps. For example, I always told my orthopaedic surgeons that patients sent to them with fractures were NOT consults ... the PMD wasn't asking for an opinion on how to treat the fracture; the PMD was asking the Orthopod to treat the fracture.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  9. #9
    Everett, Washington (20622)
    I agree with F Tessa that using a form to force the provider sending you the patient to clearly identify the service they are requesting is a great way to cover your bases. The Consult guidelines clearly state that a "request for advice or opinion" is required to report these codes.

    I have been told by our Medicare Carrier that the use of the word referral automatically calls into question the validity of using a consult code.


  10. #10
    Default Documentation
    Does anybody know where I can find Medicare's definition of what their requirements are for a provider to bill for a consult?


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