Still confused as to whether a visit is a consult or a referral?

Let’s take a look at the definition of a consultation. A consultation is a type of service provided by a physician or qualified provider whose opinion or advice regarding the evaluation and/or management of a specific problem is requested by another physician or provider. Another way of defining a consultation is a rendering of advice of your professional opinion, followed by a report of your findings to the referring physician.

According to CMS, carriers pay for a reasonable and medically necessary consultation service when all of the following criteria for the use of a consultation code are met:

• Specifically, a consultation service is distinguished from other evaluation and management (E/M) visits because it is provided by a physician or qualified non-physician practitioner (NPP) whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. The qualified NPP may perform consultation services within the scope of practice and licensure requirements for NPPs in the State in which he/she practices. Applicable collaboration and general supervision rules apply as well as billing rules;
• a request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient's medical record and included in the requesting physician or qualified NPP's plan of care in the patient's medical record; and
• after the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician.

The intent of a consultation service is that a physician or qualified NPP or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional's knowledge. Consultations may be billed based on time if the counseling/coordination of care constitutes more than 50 percent of the face-to-face encounter between the physician or qualified NPP and the patient.

A consultation visit results in the patient returning to the primary care physician who initiated the care. Diagnostic testing can be provided and billed in a consultation. If the consultation results in the physician assuming assume care of that patient, the visit is a referral and should be billed as a new patient.

In 2005, CMS published a good Medlearn Matters article (MM4215, dated January 20, 2005) regarding changes, clarifications, and reminders regarding Consultation Services CPT Codes 99241-99255. To read further about some of the highlights of this article and to understand how and when to use the consultation codes and how to ensure documentation supports the service provided, please make sure to read a continuation of this article in the November edition of the Coding Compliance Advisor newsletter due to be released after November 13th, 2009. To subscribe to this newsletter, click here. 

Written by Gina Hobert, MBA, CPC-I, CPC, CPC-H, CMOM