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patient initiated referral

  1. #1
    Rose City (Portland, Oregon)
    Default patient initiated referral
    Medical Coding Books
    Patient tells his PCP that he wants to see a specialist for a particular condition. The PCP puts in a referral.

    I believe the visit with the specialist is a New Patient visit rather than a Consult because there is not a request for advice from an appropriate source. I'm having difficulty persuading the specialist of this. I need documentation that talks about a patient initiated referral or second opinion request WITH a referring provider. Everything I have found does not talk about having a referring provider (in fact specifically says without a referring provider).



  2. #2
    Milwaukee WI
    Default Referral does NOT equal request
    Referral is a requirement of insurance companies (started with HMOs, but has expanded to a lot of carriers).

    A request for a consultation is just that - one provider requesting advice or opinion from another provider on the management of a problem/issue.

    There USED to be a code for second-opinion consults. No longer.

    If the patient initiaed the visit with your doctor, it is NOT a consultation. It is a new or established patient visit (depending on whether the patient has received any services by your physician or another physiciain of the same specialty in the same practice within the last three years).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Hartford, CT
    In the CPT book the decription under consultations (prior to the actual codes) states: A "consultation" initiated by a patient and/or family, and not requested by a physician or other appropriate source...., is not reported using the consultation codes but may be reported using the office as appropriate. (In the CPT Professional edition this is on page 17).

    Doreen, CPC

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