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Consults vs. Referrals

  1. #1
    Default Consults vs. Referrals
    Medical Coding Books
    I am beginning an audit project for physicians within our group. One particular physician can't find a difference in consults vs. referrals. I have searched and searched, but I can't seem to find the right documentation. Does any one have good documentation on this from a physician standpoint? Thanks.
    Tiffany Fischer, CPC, CEMC

  2. Smile Consults vs Referrals
    Hi Tiffany,

    The consult is a request for an opinion which may well result in the consultant taking over care of the patient.

    The referral is the direct turning over of the patient for care.

    For articles that best-describe these, you can google CONSULTATIONS vs REFERRALS and they give pretty good verbage.

    Good luck!

    Last edited by AuntJoyce; 11-16-2009 at 12:28 PM. Reason: Word omitted

  3. #3
    North Carolina

    Specifically, a consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified nonphysician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.

    A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record; and

    After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.

    The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

    Transfer of Care

    A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patients’ complete care for the condition and does not expect to continue treating or caring for the patient for that condition.When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care.
    In a transfer of care the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and level of service performed and shall not report a consultation service.

    Section 30.6.10

  4. #4

    and my MAC has suggested using this form:

    Of that will be going away in 6 weeks for Medicare, but you could probably still use it or something similar for the other payors who will continue to covere consultations.


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