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Language on Consults vs. OV

  1. #1
    Talking Language on Consults vs. OV
    Medical Coding Books
    I was told in the past that when documenting a consult it is important to avoid the words "referred by". Making such a statement kicks you out of a consult and now becomes an office visit.
    If I am wrong then please let me know. This is something I have stressed to all my physicians and now am being questioned on by new manager . Also if this is true can someone provide some documentation on this for me or point me in the right direction.
    Thank you

  2. Default
    You are correct. Once the word referral or referred is documentated then it is no longer a consult.

    For it to be a consult you have to have the 3 R's:
    1)request from another physician
    2)reason for the consult
    3)report sent back to requesting physician

    Consult is request for opinion.
    Referral is transfer of care.

    I know there is documentation on the CMS website but I had found this on our BC's website and kept it in my favorites but it seems to clarify both referrals and consults. I know the web based training module on the CMS's website that clarifies this issue.

    Provider Manual 50 November 2007
    Specific Claims Guidelines

    Consultations vs. Referrals
    A consultation is performed when a physician is asked to render an opinion to be used by the attending
    physician in the treatment of the patient. In order to bill for the consultation, the following criteria must
    be met:
    The service must be medically necessary;
    The service must have been requested by the attending physician and documented either by a
    letter or note from the referring physician or by a signed and dated note in the patient's
    records specifying the verbal request. In an inpatient setting, the request can be documented
    as part of an order in the patient's hospital records or as part of the requesting physician's
    plan in his/her progress note;
    The consultation must include the history and examination of the patient; and
    The written report by the consulting physician must be sent to the attending physician to be
    included in the patient's permanent medical records.
    A consultation occurs when, for example, a dermatologist refers a patient to a second dermatologist for an
    opinion on how to best treat the patient's acne scarring. Based on the reported opinion of the second
    dermatologist, the first dermatologist then resumes the treatment of the patient, and the second
    dermatologist bills for a consultation.
    A referral is defined as the transfer of care from one physician to a second physician when the second
    physician assumes responsibility for treatment of the patient. A referral occurs when, for example, a
    dermatologist refers a patient to a second dermatologist for the actual treatment of scarring. The second
    dermatologist assumes the care of the patient.
    In the first example, if the attending physician reviews the consulting dermatologist's recommendations
    and asks him to assume responsibility for treating the patient's acne scarring, the consultation has resulted
    in a referral. It is still appropriate for the consulting dermatologist to bill a consultation for the initial
    patient encounter.
    There may be occasions when a patient is sent for a consultation and elects to have the consulting
    physician begin treatment on the day of the initial encounter. For example, the patient lives in a different
    town than the consulting physician and does not wish to make a second trip to the consulting physician or,
    due to the patient's condition, immediate treatment is necessary. These encounters could be billed as
    consultations when the above four criteria are met.
    Follow-up visits initiated by the consulting physician should be filed using office or hospital visit codes
    for established patients (CPT codes 99211-99215 or 99231-99233). If an additional request for an opinion
    or advice regarding the same or a new problem is received from the attending physician and documented
    in the medical record, consultation codes may be used by the consulting physician.

    Hope this helps, I have more documentation if needed, I just don't have it handy right now.

  3. #3
    Post Thanks for sharing
    Thanks for sharing your knowledge codegirl0422. The three Rs really help understand the consult.

  4. #4
    Thank you so much for your help. I was beginning to doubt myself on this one. This was extremely helpful and put my new "manager" in her place (she has no billing/coding background).

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