There is always some confusion on whether to report a consultation or a referral. Is the requesting provider wanting my opinion? Does he want me to take care of this patient? Before a provider can report the service, it is important to understand the difference.
A consultation is distinguished from a referral (visit) because it is provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source. Remember the three “R’s” when determining a consultation: Request from another provider, Render the service, and Respond back to the requesting provider.
A referral is when the referring provider turns the management of the patient over for a specific problem to another provider. In this case, the “referred to” provider should bill a visit code (Office: 99201-99215).
Before reporting a consultation, ask these questions and if any are answered “NO”, do not report the service as a consultation:
- Did you receive a request for an opinion from another provider?
- Does your documentation of the service clearly demonstrate who made the request and the nature of the opinion requested?
- Have you provided a written report of your opinion/advice to the requesting provider?
- Though the referring provider may have asked for a “consultation”, should the E/M service you provided truly be reported as a consultation?
- Will your opinion be used by, and in some manner affect, the requesting provider’s own management of the patient?
- Will the referring provider be involved in subsequent decision-making about the problem for which the referral was made?
- For pre-operative “consultations”, is the service requested specifically for pre-operative clearance that is medically necessary considering the patient’s condition and the procedure planned?
Remember, Consultation codes (99241-99255) may not be reported to Medicare or any Medicare Advantage plans and most Medicaid plans. Check your payer rules before reporting a consult code.