Optometry Coding & Billing Alert

Question: What is the difference between a consultation and a referral, and how can I tell the two apart?


Missouri Subscriber

Answer: When the optometrist sees a patient and sends an opinion to the requesting physician--and then the patient returns to the requesting physician for treatment--it is usually a consultation.

If the optometrist is not asked for his opinion about the patient's problem, and he does not provide his opinion on the patient's status during the encounter, it is not a consult. CPT 2006 sports a pair of code families to represent consultations:

- Office or other outpatient (99241-99245, Office consultation for a new or established patient ...)

- Initial inpatient (99251-99255, Initial inpatient consultation for a new or established patient ...).

When the optometrist does not provide his opinion on the patient's condition during the encounter, the visit is not a consult. If you are having trouble deciding whether a visit qualifies as a consultation, ask yourself: Is the patient coming in for a consult or to get something -fixed-?

Example: Dr. P, a primary-care physician, sends one of his patients to an optometrist to check for the presence of a Kayser-Fleischer ring. In the office, the optometrist performs a level-two service. The patient then returns to Dr. P for further treatment, and the optometrist sends Dr. P a written report of his findings. In this instance, the optometrist provided a consultation. On the claim, report 99242 (Office consultation for a new or established patient -) for the consultation.

What makes it a referral? A referral is the transfer of responsibility for a patient's care from one physician to another. After the optometrist provides a referral service, he is usually the patient's primary physician for treatment of the condition. Unlike consultations, referrals do not have their own code sets. You should report referrals using the E/M codes from the new or established patient code set.