Primary Care Coding Alert

Correct use of consultation as opposed to referral can have significant impact on physician reimbursement. Unfortunately, these terms often are used interchangeably, resulting in confusion, claim denials and lost revenue.
Family physicians (FPs) find themselves on both sides of the consultation and referral equation. Many times, they act as the requesting physician, asking other specialists for advice or care for their patients. In other situations, medical colleagues seek the FPs opinion on conditions and treatment alternatives.

In either role, it is important for coding professionals to recognize that a consultation occurs when one physician requests the opinion or advice from another specialist regarding a specific aspect of patient care, while a referral entails turning the patients care over to the specialist.

According to Brett Baker, senior associate for regulatory affairs for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), HCFA recently updated and clarified its guidelines to resolve the confusion surrounding these terms (Section 15506 of the Medicare Carriers Manual [MCM]). This takes on significant importance when you recognize that a consultation carries a much higher relative value unit (RVU) than a referral does, he points out. Consultations are billed with CPT codes 99241-99275, while referrals are reported with office visit or hospital inpatient codes.

Sample RVU and Payment Comparison

Total RVUs Payment (national average)
Office visit codes
99213 1.32 $50.50
99215 3.06 $117.08

Consultation codes
99243 3.09 $118.22
99245 5.73 $219.23

What Is a Referral?

A referral is the simpler of the two concepts and has fewer requirements guiding its use, Baker says. Usually, a referral occurs when the family physician sends the patient to a specialist with the intention that the specialist assumes treatment for the patient for the condition specified and performs all followup care.

For example, a 35-year-old woman who has a history of diabetes becomes pregnant. The family physician requests that an obstetrician (ob) who has experience managing pregnancies with this type of complication assume care. The ob would provide antepartum, labor and delivery, and postpartum care to the patient. A second example may involve a teen-age patient who suffers from severe acne. The FP may refer the adolescent to a dermatologist for treatment of that specific condition.

A reverse situation may occur when a patient has selected a gynecologist as her primary care physician, as some health plans allow. However, this patient develops a mild but persistent skin rash, and the gynecologist refers her to a family physician for care. The FP would bill for an office visit, new patient (evaluation and management codes 99201-99205) or, if the patient had been seen by that physician or another family physician who belongs to the same group practice within the previous three years, with an established patient evaluation and management (E/M) service (99211-99215).

What Is a Consultation?

Alternately, a consultation is a request for a medical opinion or advice about a specific condition. Initial consultations are assigned codes from the 99241-99255 series, depending on the setting. Some coders characterize consults by pointing out they must include three clearly defined activities:

1. The originating physician must request the consultation;
2. The consultant must review the patients condition; and
3. The consultant must send a written report with findings to the requesting physician.

For instance, a family physician may notice a skin lesion on a patients back during an annual checkup. The FP sends the patient to a dermatologist, requesting a medical opinion regarding the status of the lesion. The dermatologist examines the patient and provides the doctor with a written report of his or her assessment.

Family physicians may also receive a consultation request, Baker notes. For instance, a patient suffering from diabetes may also be a candidate for knee replacement. Prior to the procedure, the surgeon requests that the FP perform a physical exam to ensure the patient is able to withstand the surgery, and to determine if the diabetes would complicate or prohibit the surgery. In this case, the FP would have received the request, reviewed the patients condition and provided the surgeon with a report. The visit would be billed as a consultation.

Some family practice coders report confusion about situations like this, noting that the surgical candidate may be a long-term patient. Even though the doctor may see the patient regularly for care unrelated to the orthopedic condition (i.e., for the flu or problems with allergies), the appointment for a preoperative physical would be classified as a consultation since the orthopedist requested the FPs opinion about this specific aspect of the patients care.

Physicians may also request medical opinions from other specialists within their group and these, too, would be classified as consultations rather than referrals.

Special Circumstances Complicate Coding

Four distinct situations involving consultations often challenge coders. These circumstances may blur the lines between consultation and referral, or raise concurrent care issues.

1. Family physician cares for patient who was initially seen in the emergency department (ED).
Family physicians are frequently called when one of their patients is being treated at the ED, and both the ED physician and the FP may see the patient. Any physician seeing a patient registered in the ED should use the ED codes. However, coders may be tempted to report the FPs service as a consultation, but instead should assign an emergency services code (99281-99285), according to Deepa Malhotra, MS, CPC, director of coding and compliance for Healthcare Information Services Ltd. in Willowbrook, Ill., which provides billing services to more than 200 physicians in the Chicago area. The emergency physician wont be seeing this particular patient again and so is turning care over to the family physician.

Alternately, the family practice coder would assign a code from the initial hospital care series (99221-99223) if the patient were admitted to the hospital after being seen by the ED physician or if the patient is admitted after the FP provided an opinion on the patients condition in the ED. The FP would bill only for the initial hospital care because all E/M services related to the admission are considered part of the initial hospital service.

2. Consulting physician initiates care.
In some instances, the consulting physician uncovers a condition that needs immediate care. This type of service falls under the definition of a consultation and can be reported as such, Baker says. The consulting physician may order tests to further evaluate the condition that prompted the request and may initiate care.

For example, a dermatologist may be asked for a consultation on a skin lesion. After assessing the abnormality, he or she removes it. Even though the dermatologist treated the condition in addition to providing the consultation, he or she may bill the visit as a consultation. Similarly, a surgeon may request that a family physician provide a preoperative physical on a patient scheduled for a hysterectomy. During the exam, the FP diagnoses strep throat and prescribes an antibiotic. Even though the doctor initiated care for the infection, the practice may code and bill the visit as a consultation. Of course, the FP must also provide a written report regarding the patients fitness for surgery.

In either case, followup services would be reported by the family practitioner as an office visit for an established patient or subsequent hospital care (99231-99233), depending on the setting.

3. Physician provides postoperative exam.
A physician who performs a postoperative evaluation of a patient at the request of a surgeon or other specialist may also report a consultation code but only if the consultant did not provide a preoperative evaluation.

If postoperative care or management were provided in the hospital, it would be coded with the appropriate subsequent hospital care codes. If these services were given in an office setting, appropriate established outpatient codes (99211-99215) would be reported.

4. Coding subsequent requests for consultation.
As noted earlier, an initial visit may be reported with the consultation code when a consulting physician deems it necessary to begin care, but followup visits must be assigned the appropriate inpatient or outpatient care codes. There are also occasions, however, when followup consultation codes (99261-99263) may be assigned. According to CPT, these may be assigned only when additional visits are required to complete the initial consultation or when the requesting physician seeks subsequent consultations. The followup consultation codes may be assigned only for care of hospital inpatients or nursing facility residents, and describe services that include:

monitoring progress;
recommending management modifications; or
advising on a new plan of care in response to changes in the patients status.

There may also be occasions when a consultation may need to be repeated. For instance, a family physician requested a consultation on a skin lesion. The dermatologist saw the patient, removed the lesion and provided the FP with a written report. Two years later, the same patient developed a second suspicious lesion. The FP again sought a consultation from the dermatologist. Both visits with the dermatologist would be reported as consultations.

Three Tips for Reporting Consultations

1. Watch your language. The single biggest mistake family practitioners make is misusing the term referral, says Malhotra. When seeking a consultation, the FP must make sure he or she doesnt say he or she is referring the patient for a consultation. When Medicare carriers or other payers see the word referring, they assume care was transferred and wont pay for a consultation. Instead, the physician should say he or she is requesting a consultation. This way, the documentation clearly supports the coding.

Likewise, the consulting physician should avoid thanking the requesting physician for a referral when providing the written report (i.e., Thank you for referring Mrs. Smith to me ). Instead, the consulting physician should use language like, Thank you for asking me to evaluate Mrs. Smith for this condition

Nor should consulting physicians state that they have evaluated the patient and are following her for this problem. This terminology also implies that a transfer of care has taken place. Instead, the consulting physician may state, I have evaluated Mrs. Smith for this problem at your request and, with your approval, will perform appropriate followup visits.

2. Document requests and reports carefully. Documentation is vital to proper payment for consultations and referrals. Medicare, for instance, requires that a request for a consultation from an appropriate source and the need for the consultation must be documented in the patients medical record. Ideally, a copy of the request is kept in the patients charts in both the family practice and the specialists office, Malhotra says.

Similarly, a written report must be sent by the consultant to the requesting physician and kept in the patients chart at both offices.

3. Appeal concurrent care denials. Medicare and other insurers may flag and deny claims submitted by two physicians for care given to the same patient on the same day (e.g., when an ED and family physician see that patient in the ED, or when an FP sees a hospital inpatient for a specific condition at the request of a surgeon).

These should be appealed, according to Malhotra, who points out that Medicare distinguishes physicians by specialty and should allow these claims because the two practitioners see the patient for different reasons. Software used by some private payers may not make this distinction and therefore reject these claims. Nonetheless, coders and billing managers should fight these denials since the charges are legitimate.