Practice Management 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 physician visits with a patient and renders an opinion from a requesting physician about a patient's condition--and then the patient returns to the requesting physician for treatment--it is usually a consultation.

If your doctor 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 ...). If your doctor does not provide her 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: -Are they coming in for a consult or to get something -fixed-? -

Consider the following example of a consult:

Dr. P, a primary-care physician, sends one of his patients to a gastroenterologist to get his opinion on a patient who has severe bouts of vomiting. In the office, the gastroenterologist performs a level-two service. The patient then returns to Dr. P for treatment recommended by the gastroenterologist, who also sends Dr. P a written report of his findings and a list of treatments rendered during the encounter.

In this instance, the gastroenterologist provided a consultation. On the claim, report 99242 (Office consultation for a new or established patient, which requires these three key components: an expanded problem-focused history; an expanded problem-focused examination; and straightforward medical decision-making) for the consultation.

While there is a -circle of care- when a doctor provides consultation services, it looks more like a -direct line of care- when the doctor performs referral services.

What makes it a referral? A referral is the transfer of responsibility for a patient's care from one physician to another. After your physician provides a referral service, she 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.