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Consultations vs. Referrals

A consultation is performed when a physician is asked to render an opinion to be used by the attending physician in the treatment of the patient. In order to bill for the consultation, the following criteria must be met:

A consultation occurs when, for example, a dermatologist refers a patient to a second dermatologist for an opinion on how to best treat the patient’s acne scarring. Based on the reported opinion of the second dermatologist, the first dermatologist then resumes the treatment of the patient, and the second dermatologist bills for a consultation.

A referral is defined as the transfer of care from one physician to a second physician when the second physician assumes responsibility for treatment of the patient. A referral occurs when, for example, a dermatologist refers a patient to a second dermatologist for the actual treatment of scarring. The second dermatologist assumes the care of the patient.

In the first example, if the attending physician reviews the consulting dermatologist’s recommendations and asks him to assume responsibility for treating the patient's acne scarring, the consultation has resulted in a referral. It is still appropriate for the consulting dermatologist to bill a consultation for the initial patient encounter.

There may be occasions when a patient is sent for a consultation and elects to have the consulting physician begin treatment on the day of the initial encounter. For example, the patient lives in a different town than the consulting physician and does not wish to make a second trip to the consulting physician, or due to the patient’s condition, immediate treatment is necessary. These encounters could be billed as consultations when the above four criteria are met.

Follow-up visits initiated by the consulting physician should be filed using office or hospital visit codes for established patients (CPT codes 99211-99215 or 99231-99233). If an additional request for an opinion or advice regarding the same or a new problem is received from the attending physician and documented in the medical record, consultation codes may be used by the consulting physician.

Last Updated January 2010