Is it a Consultation or a Referral:
When to Use Consult Codes vs. Office-visit E/Ms
Published on Wed Sep 01, 1999
Consultations and referrals for care are the lifeblood of many neurology practices. For example, a primary care physician (PCP) has a patient with severe, recurring headaches. Is it a neurological problem? Does the patient suffer from migraines? The PCP sends the patient to a neurologist in your practice, asking the specialist to examine the patient and either rule out a neurologic etiology or offer an opinion as to the cause of the problem. The neurologist performs a workup, orders several diagnostic tests, and rules out the presence of any neurological cause. He then writes a report indicating this to the PCP.
In another common situation, a person, due to illness or injury, develops a lesion on the brain causing an aphasiaan impairment in his ability to use or comprehend speech. The persons PCP knows that this neurological injury is beyond his scope of practice and refers this patient to a neurologist, asking him or her to diagnose the specific cause of the aphasia and treat the patient for the problem.
How should these visits be reported? Are they consultations (99241-99245, office or other outpatient consultation, new or established patient)? Or are they referrals (a transfer of the patients care), which the neurology practice would code with the office/outpatient evaluation and management (E/M) codes (99201-99205, new patient; 99211-99215, established patient) instead of the consult codes?
The answer for the above examples is both. The first example is a consultation. The neurologist receives a request for an opinion, evaluates the patient, and makes a recommendation back to the original physician. He does not follow the patients care.
The second example is a transfer of care of the patient for that injury. The neurologist assumes care of the patient for the aphasia and the lesion that caused it, while the PCP handles the other healthcare needs of that patient.
Telling the Difference is Tricky: Consult or Transfer of Care
Coders are frequently confused about the correct way to report consults and referrals. Many health organizations and third-party payers use conflicting and confusing terminology. For example, many managed care plans call any specialist the patient sees other than the PCP a referral, whether the specialist assumes the care of the patient or not. Members of the managed care plan are instructed to get the physician to fill out a referral form anytime they want to see a specialist. And doctors frequently consider any treatment of a patient at the request of another physician to be a consultation.
But, says Terry Fletcher, CPC, CCS-P, a healthcare coding consultant and coding educator with McVey Associates in Novato, CA, the CPT manual has specific rules to determine which visits should be reported as consultations and which ones should [...]
