Know the Ropes for Coding Consults and Referrals
Published on Sat Oct 30, 2004
Brush up on the difference to stay away from audits - and save $45 Just because another physician "refers" a patient to your urologist doesn't mean you should assume the visit is a referral or transfer of care - that is, unless the patient meets this expert criteria. "Doctors frequently say to patients, 'I'm going to refer you to a specialist to see exactly what your problem is.' But they aren't clear when they say the word 'refer,' and this can spell trouble for coders trying to choose a correct E/M service code," says Marvel Hammer, RN, CPC, CHCO, a consultant with MJH Consulting in Denver.
Let the "Three R's" Guide You: Likewise, if the urologist says he "consulted" with the patient, you shouldn't automatically choose a consult code. A "consult" as defined by CPT describes a very specific service that involves three components:
A request from another physician for a consult
An opinion rendered by the consulting physician
A report on the patient's condition sent by the consulting physician to the requesting physician (most often in the form of a consultation letter).
Using these three criteria, you can separate the consults from the transfers of care. Self-Referrals and Recommendations Don't Count If a patient visits your urologist on his own accord, or at the "recommendation" of another physician, you must select a standard outpatient E/M code (99201-99205 for new patients, or 99211-99215 for established patients) to report the service.
"The patient may have a recommendation from the attending doctor to see a physician in a particular specialty group," says Cindy Parman, CPC, CPC-H, RCC, principal of Coding Strategies Inc. in Powder Springs, Ga., but you cannot bill for a consult if "the attending physician did not specifically ask for an opinion or advice from the specialist." This request from the attending physician must be recorded and available as a part of the patient's medical record. 'Some Care' Doesn't Mean 'Transfer of Care' You may report a consult even if your surgeon schedules testing or initiates care for the patient - if the visit meets the requirements of request, render and report.
CPT Codes 2004 makes this point clearly, stating, "A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit."
And, in July 1999, CMS transmittal R1644.B3 (effective Aug. 26, 1999) clarified that Medicare will pay for a consult regardless if the consulting physician initiates treatment, as long as all consultation criteria are met and no transfer of care occurs.
Many insurance companies that see [...]
