EM Coding Alert

Remember: In a consultation, the consulting physician’s opinion is crucial.

Pulling out your hair trying to understand the differences between consultations and referrals? Well, you are not alone. Practices often stumble when it comes to correctly distinguishing between these two important concepts, but you don’t have to fall into that trap. Let us show you how to ace your consults and referrals with this expert advice on distinguishing between the two.

Always Determine “Transfer Of Care”

When trying to decide if a situation qualifies as a referral, remember the phrase “transfer of care.”

“Referral normally implies that all or a portion of the patient’s care will be transferred to a new provider,”

says Laureen Jandroep, CPC, COC, CPC-I, CPPM, founder/CEO Certification Coaching Organization, LLC in Oceanville, N.J.

Note that when a physician refers a patient to another physician, it’s for the treatment of a certain illness or condition, adds Chandra Stephenson, CPC, CIC, COC, CPB, CPCO, CPMA, CPPM, CRC, CPC-I, CCS, CANPC, CCC, CEMC, CFPC, CGSC, CIMC, COGBC, COSC, program director Certification Coaching Organization, LLC in Oceanville, N.J.

Takeaway: When your physician refers a patient, he transfers that patient’s care to another physician he believes can better treat the patient’s specific problem. The patient won’t return to the referring provider for additional care for that specific problem.

Learn When Using A Referral is Appropriate

Look at this example from Jean Acevedo, LHRM, CPC, CHC, CENTC, president and senior consultant with Acevedo Consulting Incorporated in Delray Beach, Fla.: For the past three years, Dr. Nolan, a primary care physician, has treated his patient, Mr. Johnson, for diabetes (E11.9). During today’s encounter, Dr. Nolan notices that Mr. Johnson has some diabetic neuropathy (E11.40) and his blood sugar is 312 (E11.65). Concerned, Dr. Nolan refers Mr. Johnson to Dr. Vogt, an endocrinologist.

Application: This is a referral because Dr. Nolan transferred Mr. Johnson’s care to the endocrinologist, Dr. Vogt, whom he believed could help get the specific medical condition, diabetes, under control. Dr. Nolan might want to be kept up-to-date on Mr. Johnson’s condition; however, he wants Dr. Vogt to manage it throughout its on-going course.

Choose the Right Referral Code

Since we’ve established that referrals are a transfer of care, you should use E/M office or inpatient codes to report these services, says Catherine Brink, BS, CMM, CPC, president of Healthcare Resource Management in Spring Lake, N.J.

For example, you would code referrals performed in the office with 99201-99205 (Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components …) for new patients and 99212-99215 (Office or other outpatient visitfor the evaluation and management of an established patient, which requires at least 2 of these 3 key components …) for established patients.

Realize Opinion Is Key to Consultations

In contrast to a referral’s transfer of care stipulation, a consultation is all about the consulting provider’s opinion.

“In the simplest of terms, a consultation is a type of service where another physician or nonphysician practitioner requests a doctor’s advice, opinion, or recommendations about a patient’s problem, that doctor sees the patient, and he provides a written report back to the requesting clinician with his advice, opinion, or recommendations,” says Acevedo.

Remember the 3 Rs: To correctly code a consult, the documentation must reflect three criteria — an opinion was requested, a service was rendered, and the opinion was reported back to the requesting provider.

When documenting consultations, your provider’s medical record must include the medical necessity for the consultation. The medical record must also include the written request by the originating physician to the consulting physician, indicating a medical reason as to why the patient is being sent, adds Brink.

Special note: Although the consulting provider’s opinion may be that it is best to take over the care of the patient, you can still consider the initial visit a consultation if an opinion was the intent of the request, explains Stephenson. The report back to the requesting provider would also indicate that the recommendation is to remain with the consultant throughout the course of treatment.

Master The 2 Kinds of Consultations

Once you’ve identified that your provider did, in fact, perform a consultation, you need to choose the right code to report. Consultations are categorized into two types: inpatient and outpatient, as follows:

A. Office/other outpatient consultations (99241-99245, Office consultation for a new or established patient, which requires these 3 key components: …): For example, a family physician sees a patient complaining of chest pain, off and on. The family physician requests a consultation from a cardiologist to get the cardiologist’s opinion about the problem (off and on angina). A written request for the consult, including the reason for the consultation, and, after seeing the patient in his office, the cardiologist provides his opinion in a return letter back to the family physician. You should choose a code in the 99241-99245 range to report the cardiologist’s services in this scenario.

B. Inpatient consultations (99251-99255, Inpatient consultation for a new or established patient, which requires these 3 key components: …): According to Brink, this is an example of an inpatient consultation: A pulmonologist caring for the inpatient with Chronic Obstructive Pulmonary Disease (COPD) or emphysema requests an opinion, or consult, for this patient because he has complaints of chest pain. You identify a request, rendering of service, and a return report in the documentation. Therefore, you can report a code in the 99251-99255 range for the cardiologist in this case.

Note: Although Medicare stopped accepting claims for consultations as of Jan. 1, 2010, some private payers still accept consultation codes. Check with your payer to ensure you are not leaving money on the table.