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Consult Versus Referral

Consultation (Note: in 2010 Medicare no longer recognizes Consultation Codes)

A consultation has four elements that distinguish it from other services:

  1. Consultations involve rendering an opinion or giving advice only. 
  2. Consultations must be requested by the patient's attending physician or other appropriate source and the need documented in the medical record. 
  3. Consultations do not involve active management of patient problems although the consultant may initiate diagnostic and/or therapeutic services. If responsibility for ongoing care is assumed, subsequent services are no longer consultations. 
  4. Consultations include a formal report containing the opinion or advice that was sought.

 Consultation: Services rendered by a physician whose opinions and/or advice is sought for the evaluation and/or management of a specific problem. If the visit is for a consultation, the code should be selected from the following ranges:

 

Office/Outpatient Service 99241 - 99245
Hospital 99251 - 99255
Hospital Follow-up 99261 - 99265
Confirmatory 99271 - 99275

Codes 99271 - 99275 are assigned when the consulting physician has been requested to confirm the medical treatment and/or a surgical procedure, as in the case of providing a second or third opinion. Unlike other consultations, confirmatory consultations provide only an opinion and/or advice. Modifier -32 should be reported with all confirmatory consultations.

 Consultation

  1. Suspected problem.
  2. Undetermined course of treatment.
  3. Attending physician to decide who will manage patient care...this is undetermined at time of the consult.
  4. Consulting physician must submit a written report to the requesting physician listing findings and suggestions.

 Referral:

Transfer of total or specific care of a patient from one physician to another. If the visit is an initial evaluation for a patient that has been referred, the CPT code would be selected from the following ranges:

 

New Patient 99201 - 99205
Established Patient 99211 - 99215

Referral

  1. Known problem.
  2. Prescribed and known course of treatment.
  3. When patient is referred to specialist, it is with the intent of transferring management of total care or a portion of patient care to the other provider
  4. No written letter or report is required.
 
 
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