# consult vs referral



## bwerner (Jun 30, 2009)

Hello,

We had a seminar last night with a physican that knows alot about E&M coding. I am disagreeing with him on a certain grey area. I would like to have any advice regarding this subject because I have to sell it to him.

Okay, Senario: Dr. A Family practice, has a patient with hemtachezia, Dr. A sends him to Dr. B surgeon for a colonoscopy.

Does Dr. B charge a consult visit or a new patient E&M? 

The seminar Dr., says it is a consult. I don't agree because Dr. B is going to assume care of that patient for a known problem. He isn't going to give his advise/opinion and send him back to Dr. A.  

Any feedback or opinion's would be great!

Becky Werner, CPC, CCS-P


----------



## mitchellde (Jun 30, 2009)

I sort of lean toward consultation although I believe it could be better worded.  The patient has a dx which is a symptom and it could be that he is asking Dr. B for an opinion of what is causing this symptom, and colonoscopy might help with Dr. Bs evaluation..  On the other hand if Dr. A has determined he wants a colonoscopy so the HE may better make a dx and he needs Dr. B to perform this exam then I agree no consult.


----------



## bwerner (Jun 30, 2009)

Okay, so Dr. B evaluates and does a colonoscopy, let say, he finds colon polyps. He is going to bx them, have a follow up with the patient, tell him how he needs to follow up within so many years but he isn't going to send him back to Dr. A to do anything in regards to this problem because he assume care of the problem and delt with it. 

I believe it is more of a referral. He was referred to Dr. B and Dr. A is expecting Dr. B to evaluate and treat the patient for the condition for which the patient is being referred. The services of Dr. B would not be reporting using consultation codes. On the other hand, if physican A makes a request for a consultation to physican B, it is expected that physican B will provide Dr. A with his or her advice or opinion and that the patient will return to Dr. A for any necessary treatment.

Let me know what you think?


----------



## rthames052006 (Jun 30, 2009)

bwerner said:


> Hello,
> 
> We had a seminar last night with a physican that knows alot about E&M coding. I am disagreeing with him on a certain grey area. I would like to have any advice regarding this subject because I have to sell it to him.
> 
> ...



Becky,

I would have to get further clarification from Dr. A as to his intent, it sounds like a transfer of care for this particular problem, but too could be out of Dr. A's speciality and he sent this pt to a specialist for a consult and treat also.


----------



## mitchellde (Jun 30, 2009)

I go by the spirit of the request.  Just because the findings of the consult reveal that that Dr. B is better able to address the problem does not detract from the fact that it was a consult from the beginning.  Assuming it was in fact a consult.


----------



## dmaec (Jun 30, 2009)

as long as Dr A  
REQUESTS that Dr B see the patient 
REASON (Dr A states to Dr B the reason he's REQUESTING the consult)
RENDER (Dr B gives his/her advice)
REPORT (Dr B sends a report of his/her findings back to Dr A)

then, it's a consult.  

In your scenario - Dr A can't help the patient anymore, it's beyond his help at this point, so he sends the patient to Dr B for "Dr B's" experise - his opinion - basically - "what do you think Dr B, surgery? or some other measures to try to fix the problem first?"... Dr B, knows why he's seeing the patient AT THE REQUEST of Dr A... Dr B examines patient, RENDERS his advice (surgery or not)... and REPORTS back to Dr A  "here are my findings" (I think surgery, and we'll take it from there......).....


I agree with the seminar doctor - I'd call it a consult... the patient is being sent there for Dr. B's expertise/opinion on what to do next.


----------



## LLovett (Jun 30, 2009)

The fact that it is beyond the original doctors ability to handle the problem, he recognizes this and sends them to someone who can handle it, screams transfer of care to me.

If he can't fix it or won't be following it, even with an opinion from a specialist, how could it be a consult?

It's not what the specialist documents, you could make any visit look like a consult (believe I have surgeons that do this every day) but the intent is what drives it. If they go back to the original providers note and it doesn't support he wanted an opinion on how to treat this problem, you don't have a consult no matter how good your documentation looks.

Just my opinion,

Laura, CPC


----------



## bwerner (Jun 30, 2009)

Okay, I agree with all of this but there is alot of confusion with it. It all depends on how it happens and how it is documented. These senario's happen all the time within our group. Dr. A has his nurse send over the records to Dr. B and Dr. B evaluates and does his surgery or whatever and  sends his documentation back to Dr. A.

So, to code this as a consult. Do I need a written request from Dr. A, not just chart notes? Also, Dr. B has to document that "patient is here for a consult from Dr. A". Also, is just cc: Dr A, at the end of the dictation considered the report?


----------



## bwerner (Jun 30, 2009)

Katmryn78-

When your surgeons mark a consult and documentation and requests doesn't support a consult, do you mark it down or do you charge the consult whether you agree with it or not?


----------



## LLovett (Jun 30, 2009)

I take it down to established or new. 

The problem I run into with my surgeons is they dictate a letter on every visit for every patient back to the primary care provider. So just picking up a note it would look like a consult when in fact it could be a surgery follow-up 99024.

You don't have to have a written request from the requesting provider but it must be documented in the consult note and supported by the requesting providers documentation as well.

If you have a shared EMR the cc should be sufficient for your report back providing the system can track the note and show the requesting provider did get it.

Laura, CPC


----------



## bwerner (Jun 30, 2009)

We don't have a EMR yet, it is on it's way.

So, if the requesting Dr's dictation says in it, that they are sending him over to the surgeon for whatever problem they are having, is that enough for a request?

I still think it is a transfer of care of a particular problem and should not be coded as a consult. My surgeon now, marks a new or establish visit. This Dr. that came, is telling him to charge it as a consult everytime when a doctor of ours of different speciality sends him a patient with a known problem. I'm not sure what to do.


----------



## mitchellde (Jun 30, 2009)

I agree it can be confusing but I agree with Laura.  If the Doc A knows what is wrong and it is beyond his expertise then to me that is a transfer of care, but lets look at a couple of things, 
-- Dr. A knows his pt has rectal bleeding and requests a colonoscopy for his further evaluation.  I say no consult he is requesting another physician perform a specific procedure.
-- Dr. A knows his pt has rectal bleeding and requests a specialist evaluate the patient and suggest a colonoscopy as all other diagnostics have turned up negative.  I call this a consult, it really is up to the specialist to determine the appropriate test and he is being asked for an opinion.
-- Dr. A knows his patient has say rectal cancer, he requests an oncologist to see the patient and take care of this issue.  No consult, clearly a transfer of care.
-- Dr. A knows his patient has rectal cancer and request an evaluation by an oncologist for information on the appropriate type of antineoplastic treatment.  I say consult, the specialist's opinion is being requested as to what type of treatment.
This is the way I look at the different scenarios, I hope this is of some benefit.


----------



## Karolina (Jul 1, 2009)

A lot of good stuff. My take on it is as follows. First ask yourself what Dr. A wanted to accomplish by sending the patient. I believe we are trying to figure out Dr. B's code here. 
If Dr. A said, I can't help this patient - Dr. B pls. take over -> transfer of care, no doubt.
If Dr. A said, hmmm, let me see what my colleague, Dr. B, thinks about this - maybe s/he can give me some insights on how to help this patient -> consult, so long as the famous Rs are fulfilled. It is OK for Dr. B to initiate the treatment (surgery) as long as the initial intent was for a consult.
Dr. B of course needs to send a report back to Dr. A, this is satisfied by sending a cc or a letter. In case of a shared medical record the reporting back is satisfied since both providers have access to the same record, thus a separate report is not required.
Hope this helps.


----------



## mitchellde (Jul 1, 2009)

I agree!


----------

