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
â€˘ The service must be medically necessary;
â€˘ 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 patientâ€™s
records specifying the verbal request. In an inpatient setting, the request can be documented
as part of an order in the patientâ€™s hospital records or as part of the requesting physicianâ€™s
plan in his/her progress note;
â€˘ The consultation must include the history and examination of the patient; and
â€˘ The written report by the consulting physician must be sent to the attending physician to be
included in the patientâ€™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 patientâ€™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 dermatologistâ€™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
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 patientâ€™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.
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