AAPC - Back to school
Results 1 to 3 of 3

Thread: referral v consults

  1. #1
    Join Date
    Apr 2007

    Default referral v consults

    AAPC: Back to School
    If the doctor is billing for a consultation and says in his letter back to the referring provider or any where on his office note that this is a referral is this still a consultation?

  2. #2
    Join Date
    Apr 2007

    Default same problem in our office

    pamfran, sounds like this consult stuff is getting more confusing. In the office I work in, the doctors are saying anytime a patient is referred to them it is a consult. They will not accept transfer of care until they do an initial evaulation themselves with the patient eventhough the referring physician gives a diagnosis and attaches his notes. Also I am looking for some clarification about consultations. I think Medicare created a big mess when they decided to do away with consultations. I wish all consults went away. I look at consults like this, 1 a referring physician sents a request specifically for a consult not just a note saying he is referring a patient to a specific clinic 2 the consulting doctor does his hpi, exam and mdm. Now here is the part where some of my coworkers and I disagree... I say that if our doctor treats the injury, illness and notes the patient is to follow up with him regarding this injury or illness, I believe this is a transfer of care and it is a new patient visit. On the other hand if our doctor only sends the patient for mri, xray, pt and sys patient to return to evaulate this particular treatment I would count this first visit as a consult. I could go on but everything sometimes start to run together. If you care to discuss this sometime let me know.

    Last edited by coderforlife; 03-23-2010 at 09:44 PM.

  3. #3
    Join Date
    Apr 2007
    Milwaukee WI

    Default One more time ...

    Physicians frequently use the terms "referral" and "consult" interchangeably. No matter how many time we, as coders, try to educate them on the differences, they don't get it.

    But per CMS (before 2010) the thing that decides whether a visit is a consultation is the intent of the physician who sent the patient to you.

    So if Dr A sends a patient to Dr B seeking Dr B's advice/opinion on management of patient's problem, then it is a consultation. Dr B MAY determine as a result of his evaluation of the patient (which is a consultation) that treatment or diagnositic tests are warranted, and may even perform those on the same date of service. This does NOT change the fact that the E/M is a consultation.

    If Dr A sends a patient to Dr B for TREATMENT of a problem (Dr A already knows what the issue is and what the recommended treatment is, but Dr A doesn't do "that" so he send patient to Dr B) then it is a transfer of care and the E/M would be a new or established patient visit.

    Now, as if the waters weren't already muddy enough ... the AMA changed the definition of Consultations in the 2010 CPT book (Professional edition, pg 16): A consultation is a type of evaluation and management .... or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem." (Emphasis added by FTB)

    All that being said. If the patient is covered by Medicare you cannot bill a consult code in any case (and in some states MedicAID has decided to follow MediCARE rules). My guess is that the commercial carriers are all going to jump aboard this ship before we even figure out where the ship is headed.

    Remember that AMA owns the CPT. The correct way to CODE something comes from following the CPT guidelines. CMS determines what they will pay for. Whether we can BILL a service and how we will get paid (or not) for a given procedure is determined by the carrier.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

Similar Threads

  1. Referral to OB
    By Manugal1 in forum Medical Coding General Discussion
    Replies: 0
    Last Post: 08-06-2014, 07:55 AM
  2. PT\OT referral
    By veeramani14 in forum Internal Medicine
    Replies: 0
    Last Post: 04-23-2013, 09:28 AM
  3. Consults VS Referral
    By medicalsec in forum E/M
    Replies: 3
    Last Post: 03-21-2013, 11:28 AM
  4. Referral
    By nyyankees in forum E/M
    Replies: 3
    Last Post: 04-20-2011, 08:54 PM
  5. referral for Consults
    By baldi18 in forum Dermatology
    Replies: 2
    Last Post: 10-07-2008, 01:04 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.