Three Keys to Code Consults vs. Referrals
Published on Sat Jan 01, 2000
Consultant codes are initiated when one physician requests an opinion or advice from another physician, says Jan Johnson, executive vice president of The Profile Group in St. Paul, Minn., which advises hospitals and physicians on reimbursement and compliance issues. In determining whether a patient visit is a consult (99241-99245, office or other outpatient consultation), she says to look for these three elements to be present:
1. The patient has to have been sent by another
physician asking for the specialists opinion;
2. The receiving physician must examine the patient
and document in writing what was done; and
3. The pulmonologist must then send recommend
dations back to the physician who sent the patient.
Consider a case where a primary care physician (PCP) has a patient complaining of a cough that has lasted more than a month. The PCP sends the patient to a pulmonary specialist, asking in a letter for a diagnosis. The pulmonologist examines the patient, diagnoses the problem and sends the PCP a suggested treatment plan to carry out. Consult or referral? Most would say this is a clear-cut example of a consult.
What if the PCP asks a pulmonologist to evaluate and treat the patient for the cough? Is that a consult or referral? Most say thats a referral because the PCP is transferring care of the patient for that problem to the specialist.
The first thing the carriers look for is the name of the physician who is sending the patient, says Carole Fatato, division coordinator at Cooper Hospital Pulmonary and Critical Care in Camden, N.J. She has had claims based on consultant codes denied when the name of the sending physician was inadvertently left off the claim. If they dont have a referring physician, theyll [carriers] automatically deny it, she warns.
Some experts contend that the regulations say a transfer of care occurs only if a physician transfers total care for the patient to the specialist. Ray Painter, MD, of Physician Reimbursement System in Denver, says that unless the specialist is asked to take over total care for the patient, then a consultation applies. If that referring physician is going to see that patient again, then the transfer of the total care of the patient probably didnt occur, Painter says.
For example, if a patient has a chronic pulmonary disease and the PCP wants to hand all of that patients care over to a pulmonary specialist and doesnt want to see the patient again, that would be a transfer of care. But if this is an acute problem the patient is having, and he will go back to see the primary care physician after that problem is corrected, then that would not [...]
