Dermatology Coding Alert

Question: I've seen information containing definitions that differ from CPT. I've read that if a requesting physician asks for an opinion about a condition and the consulting physician sends the patient back to the requesting physician for treatment that this constitutes a "consultation." A "referral" is when a patient's care for a condition is transferred from one physician to another, according to the article.

The 2006 CPT book states that "A consultation is a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit."

Also, the CPT book does not define "referral." Which definitions are correct?


Oklahoma Subscriber

Answer: CMS updated Medicare rules for consultations on Jan. 1, 2006. The AMA then clarified its opinion on what qualifies as a consultation in the 2007 CPT manual issued in late November. The 2007 CPT has tried to clarify the AMA position as opposed to the very stringent position of CMS. You can download Medicare's updated consultation rules to the Medicare Carriers Manual Chapter 12, section 30.6.10 from cms.hhs.gov/transmittals/downloads /R788CP.pdf (changes appear in red).

Bottom line: Apply the CMS rules for government payers, and apply the AMA rules for private payers.

The answers to the Reader Questions were provided and/or reviewed by Barbara J. Cobuzzi, MBA, CPC, CPC-H, CPC-P, CHCC, director of outreach programs for the American Academy of Professional Coders, the coding organization in Salt Lake City.