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Thread: Here we again! Consultation Vs Transfer of Care

  1. #1

    Default Here we again! Consultation Vs Transfer of Care

    AAPC: Back to School
    I just read the following statement in the June 2011 General Coding Surgery Alert issue regarding transfer of care vs. consultation. I finally think I get it straight and then I read a different interpretation. I work for general surgeons and most often the diagnoses is known when the patient gets to our office. Tests have been already been done by the primary or other specialist to determine the diagnoses, so we know if the patient has gallstones, breast cancer, colon cancer, etc. We had been coding these as a consultation if we had a referral that specifically requested a consultation (assuming that they still wanted the doctors opinion) or use the word evaluation, otherwise we have felt that these were a transfer of care because the doctor referring the patient to us was not asking for our opinion, nor did they plan to treat the patient any further for the condition. Often doctors in our area just give the patient our phone number and fax over the test results, so we don't know the intent of the referring physician. The doctor is referring the patient to us for treatment of the known diagnoses and the patient is not going to return to the referring doctor for treatment for this particular condition. In the question and answer section below, it was worded that it can be justified by stating that the patient may be treated for RUQ pain. This seems rather misleading because you already know the none DX is what is causing the RUQ pain. You are stating the symptoms instead of the known diagnoses which was determined before the surgeon saw the patient. Help! I don't know where to draw the line for this anymore. Of course, we don't have to worry about this anymore with Medicare or the senior plans since they have stopped consultations due to the confusion, but I still feel that all of the conflicting articles that I read still spin this issue in different directions, and I certainly want to bill the other carriers correctly.

    Please review the following:

    Article from June 2011 General Surgery Coding Alert/Volume 13/Number 7/Page 46

    Questions and Answer Section:

    Distinguish Consultation, Transfer of Care


    We commonly see patients referred by another physician for
    conditions such as infected gallbladder, or breast or colon
    cancer. Our surgeon performs an office exam that frequently
    results in a later surgery. Should we code these as consultations
    or transfer of care? Do we need a written notice from the
    referring physician for consultations?
    Texas Subscriber

    Typically, the situations you describe involve a consultation,
    such as 99241 (Office consultation …), not a transfer of care.
    You do not need to have anything in writing from the requesting
    physician to bill a consult. That said, you should abide by some
    protocols to ensure you’re billing these cases correctly.

    Document consult: Although you don’t need a written
    request, you do need to document a consultation service.
    The documentation can come from the referring physician or
    the consultant. On your end, you can justify the referral by
    specifically stating in your note who referred the patient, and
    for what condition. For instance, the note might say “Dr. Smith
    referred Mrs. Jones for evaluation and possible treatment of
    right upper quadrant pain.”

    Transfer of care is different: When one physician is already
    treating the patient for a specific condition and transfers that
    care to a different physician, the situation is a transfer of care
    rather than a consultation. You won’t often have this situation
    in a surgical practice. Typically, ongoing patient care reverts to
    the referring physician following surgery.

    Any opinions?


    Last edited by medicalsec; 07-03-2011 at 11:12 AM.

  2. #2
    Join Date
    Apr 2007
    Columbia, MO


    I do not know who wrote that but to say you do not need something in writing is incorrect. The rules of a consult is the 3 Rs. You must document a REQUEST from the provider to show you were asked to RENDER back to them a decision or opinion for an issue in question, and you communicate this thru a written REPORT. In addition many HMO payers will not pay the specialist unless proper consultation steps are taken.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Join Date
    Apr 2007
    York, Pa


    I see where your confusion is coming in. What publication was this article in again? Sheesh...

    I don't agree with the article. If your provider is being consulted, why would you not have something in your files from the requesting provider? Your provider should have something in writing, verbal for this "consult" and then your provider should be sending a letter back to the referring dr with his/her recommendations for plan of treatment etc...

    Just my 2 cents here.
    Roxanne Thames CPC, CPC-I, CEMC

    "Remember the greatest gift is not found in the store but in the heart of true friends"

  4. #4


    It was in the General Surgery Coding Alert, June 2011 issue (Volume 13, Number 7/Page 46). It is a monthly coding magazine that our office has purchased on a yearly subscription. It was a question that was sent in by a reader in the Q @ A section. I cut and pasted the article, so it is word for word. I believe in 2010 some of the language was changed regarding the explanation of consultations per CPT. I understand (maybe incorrectly?) that it clarifed that a doctor could immediately set up a treatment plan after his assessment, and that it would still be considered a consultation, but I thought that the request from the referring doctor had to be very clear, so I was amazed that a highly respected coding magazine would say that most referrals to a surgeon would be a consultation. It seemed to reverse my whole belief in how to determine what is a consultation. In my mind, without anything in writing indicating the referring doctors intent that it would be considered a transfer of care, especially if they sent us all the test results and we know that the patient is coming to our office for something that they can no longer treat, breast cancer, gallbladder, colon cancer, etc. In my mind, this is why Medicare did away with the consultations, and now a respected coding magazine is making statements that would seem to support an incorrect understanding. Also in the above statement from the coding magazine, it seems that they are trying to justify the consult by stating the symptoms instead of the already known DX? If they do not put it in writing that they are requesting a consultation or an evaluation, I assume that they do not need any other information to clarify the treatment or the dx.

    PS. I just did some other research and pulled up the following from our own AAPC site:

    First Look: Changes to CPT® 2010 Go Beyond Codes
    October 21st, 2009
    The CPT® 2010 code book includes some changes that will take many coders by surprise. Here’s a synopsis:

    Consult Codes. While the Centers for Medicare & Medicaid Services (CMS) grapples with the idea of deleting these codes, the American Medical Association (AMA) extends their life into 2010 — changing only the language in the outpatient and inpatient coding instructions. For 2010, a consulting physician may assume responsibility for the management of all or a portion of the patient care after completing the consultation. What remains from 2009 are guidelines that say the consult must be requested by another provider, and that a report is returned to the requesting provider with the opinion of the consulting physician.

    I would intepret this to mean that they can accept immediate ownership of that patient on the day of the consultation, but we would still need to know the intent of the referring physician, and I can't see how that is possible without having something in writing or a phone call from the referring physician that is documented in the chart. I would say that almost 5 out of 10 appointments are made by patients that have just been given our phone number to call, and no supporting records have been sent from the primary. Also, what seems to be confusing to me is their statement that they are not transferring care because they did not treat the patient for the condition in the first place. I would think that ordering tests etc. to come up with the diagnoses would be treating the patient for the condition? I have never seen a referring doctor that sends a patient to a surgeon for RUQ pain. They have usually already determined the dx by testing, and they often just fax the results with nothing stating that they are requesting a consultation.




    Last edited by medicalsec; 07-03-2011 at 12:02 PM.

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