Medicare Compliance & Reimbursement

Question: What's the difference between a consult and a referral? How, for instance, would I report the service if my surgeon received a "consult and treat" request from another physician?

Answer: You may want to clarify with the "consulting" physician what his intent was in sending the patient to your surgeon.

To report a consult code (99241-99255), you must be sure that the medical record reflects all the components that make up a consultation:

1. There must be a request from one physician (or other appropriate source) that your surgeon see the patient

2. The requesting physician must clearly indicate the reason for the consultation

3. The consulting physician (your surgeon) must provide a written report back to the requesting physician that describes the consulting physician's findings, recommendations, etc.

Essentially, the requesting physician says to the consulting physician, "You have expertise in this area, and I need a recommendation on how to treat the patient with problem X."

Although the consulting physician may actually assume care of the patient's problem in a subsequent visit (a "transfer of care"), the initial visit occurs for the purpose of providing the requesting physician with a specialist's advice on how to treat his patient.

A "referral," on the other hand, assumes that one physician is allowing another physician to take over care of the patient (which would also qualify as a transfer of care). The first physician is not requesting the second physician's opinion or advice, and there is no requirement that the second physician share his findings or plans for treating the patient with the referring physician.

To report an E/M visit with a patient who was referred by another physician, you would use the appropriate level new or established inpatient or outpatient visit code.

Example: In a group of surgeons, one provider specializes in spine surgery and another specializes in skull-base surgery. The spine surgeon sees a new patient who presents with headaches. The neurosurgeon orders an MRI of the brain, which shows a tumor that the spine surgeon does not treat. The spine surgeon refers the patient to the skull-base surgeon in his practice to take over the care of the patient.

This is not a consult, because the spine surgeon is sending the patient to his colleague to care for this new problem. Instead, you would report the appropriate outpatient visit code (99201-99215).