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Consultations vs. Referrals

A consultation is a type of evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition/problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem. In order to bill for the consultation, the following criteria must be met:

A consultation initiated by a patient and/or family, and not requested by a physician or other appropriate source is not reported using the consultation codes but may be reported using the office visit, home service or domiciliary/rest home care codes as appropriate.

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 the process whereby a physician or other qualified healthcare professional who is providing management for some or all of a patient's problems relinquishes this responsibility to another physician or other qualified healthcare professional who explicitly agrees to accept this responsibility and who, from the initial encounter, is not providing consultative services. The physician or other qualified healthcare professional transferring care is then no longer providing care for these problems though he or she may continue providing care for other conditions when appropriate.

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/her 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 stated criteria are met.

If subsequent to the completion of a consultation the consultant assumes responsibility for the management of a portion or all of the patient's condition(s), the appropriate Evaluation and Management services code for the site of service should be reported.

Follow-up visits in the consultant's office or other outpatient facility that are initiated by the consultant or patient are reported using the appropriate 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 another physician or other appropriate source and documented in the medical record, the office consultation codes may be used again.

Last Updated June 2015