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referral v consults

  1. #1
    Default referral v consults
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    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
    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 10:44 PM.

  3. #3
    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

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