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

  1. #21
    Join Date
    Apr 2007
    Columbia, MO


    AAPC: Back to School
    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.

    Debra A. Mitchell, MSPH, CPC-H

  2. #22
    Join Date
    Apr 2007
    Athens, Ga.


    Thanks Penny and Debra!
    Walker Bachman, CPC, CPPM

  3. #23

    Default 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.

  4. #24
    Join Date
    Apr 2007


    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

  5. #25


    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.

  6. #26

    Default 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

  7. #27
    Join Date
    Apr 2007
    Milwaukee WI

    Default 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 by FTessaBartels; 11-09-2011 at 12:25 PM.

  8. #28

    Default 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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