Consult Vs Referral

15506. CONSULTATIONS (Codes 99241 - 99275)

A.Consultation Versus Visit.--Pay for a consultation when all of the criteria for the use of a consultation code are met:

1) Specifically, a consultation is distinguished from a 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 (unless it is a patient-generated confirmatory consultation).

2) A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record.

3) After the consultation is provided, the consultant prepares a written report of his/her findings which is provided to the referring physician.

Consultations may be billed for time if the counseling/coordination of care constitutes more than
50 percent of the face-to-face encounter between the physician and the patient. The preceding
requirements must also be met.

B.Consultation Followed By Treatment.--Pay for an initial consultation if all the criteria for a consultation are satisfied. Payment may be made regardless of treatment initiation unless a transfer of care occurs. A transfer of care occurs when the referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral, and the receiving physician documents approval of care in advance. The receiving physician would report a new or established patient visit depending on the situation (a new patient is one who has not received any professional services from the physician or another physician of the same specialty who belongs to the same group practice, within the past 3
years) and setting (e.g., office or inpatient).

A physician consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit. Subsequent visits (not performed to complete the initial consultation) to manage a portion or all of the patient's condition should be reported as established patient office visit or subsequent hospital care, depending on the setting.

C.Consultations Requested by Members of Same Group.--Pay for a consultation if one physician in a group practice requests a consultation from another physician in the same
group practice as long as all of the requirements for use of the CPT consultation codes are met. (See §§15506A and 15501.H.)

Limited licensed practitioners, e.g., nurse practitioners or physician assistants, may request a consultation. They may perform other services within the scope of practice for limited licensed practitioners in the State in which they practice. Applicable collaboration and general supervision
rules apply as well as billing rules.

D.Documentation For Consultations.--A request for a consultation from an appropriate source and the need for consultation must be documented in the patient's medical record. A written report must be furnished to the requesting physician.

In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician and the consultant, the request may be documented as part of a plan written in the requesting physician's progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record. In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting
physician or if the consultant's records show a specific reference to the request. In this setting, the consultation report is a separate document communicated to the requesting physician.

E.Consultation for Preoperative Clearance.--Pay for the appropriate consultation code for a pre-operative consultation for a new or established patient performed by any physician at the request of a surgeon, as long as all of the requirements for billing the consultation codes
are met.

F.Post-Operative Care By Physician Who Did Pre-Operative Clearance Consultation.--Advise physicians that if, subsequent to the completion of a pre-operative consultation in the office or hospital, the consultant assumes responsibility for the management of a portion or all of the patient's condition(s) during the post-operative
period, the consultation codes should not be used. In the hospital setting, the physician who has performed a pre-operative consultation and assumes responsibility for the management of a portion or all of the patient's condition(s) during the post-operative period should use the appropriate subsequent hospital care codes (not follow-up consultation codes) to bill for the concurrent care he or she is providing. In the office setting, the appropriate
established patient visit code should be used during the post-operative period.

A physician (primary care or specialist) who performs a post-operative evaluation of a new or established patient at the request of the surgeon may bill the appropriate consultation code for evaluation and management services furnished during the post-operative period following surgery
as long as all of the criteria for the use of the consultation codes are met and that same physician
has not already performed a pre-operative consultation.

G.Surgeon's Request That Another Physician Participate In Post-Operative Care.--If the surgeon asks a physician who had not seen the patient for a pre-operative consultation to
take responsibility for the management of an aspect of the patient's condition during the post-operative period, the physician may not bill a consultation because the surgeon is not asking the physician's opinion or advice for the surgeon's use in treating the patient. The physician's services would constitute concurrent care and should be billed using the appropriate level visit codes. See §15506 subsection F if the physician did a pre-operative clearance consultation.

H.Examples of Consultations--

1.An internist sees a patient that he has followed for 20 years for mild hypertension and diabetes mellitus. The patient exhibits a new skin lesion and the internist sends
the patient to a dermatologist for further evaluation. The dermatologist examines the patient and removes the lesion which is determined to be an early melanoma. The dermatologist dictates and forwards a report to the internist regarding his evaluation and treatment of the patient.

2.A general ophthalmologist diagnoses a patient with a retinal detachment. He sends the patient to a retinal subspecialist to evaluate the patient because the general
ophthalmologist does not treat this specific problem. The retinal subspecialist evaluates the patient and ubsequently schedules surgery. He sends a report to the referring physician explaining his findings and the treatment option selected.

3.A family physician diagnoses a patient with diabetes mellitus. The family physician asks the ophthalmologist for a base line evaluation to rule out diabetic retinopathy.
The ophthalmologist examines the patient and sends a report to the family physician on his findings. The ophthalmologist tells the patient at the time of service to return in one year for a follow-up visit. This subsequent follow-up visit should be billed as an established patient visit in the office or other outpatient setting, as appropriate.

4.A rural family practice physician examines a patient who has been under his care for 20 years and diagnoses a new onset of atrial fibrillation. The family practitioner sends
the patient to a cardiologist at an urban cardiology center for advice on his care and management. The cardiologist examines the patient, suggests a cardiac catheterization and other diagnostic tests which he schedules and then sends a written report to the requesting physician. The cardiologist subsequently routinely sees the patient once a year as follow-up. Subsequent visits provided by the cardiologist should be billed as an established patient visit in the office or other outpatient setting, as appropriate. Other routine care continues to be followed by the family practice physician.

5.A family practice physician examines a female patient who has been under his care for some time and diagnoses a breast mass. The family practitioner sends the patient
to a general surgeon for advice and management of the mass and related patient care. The general surgeon examines the patient and recommends a breast biopsy, which he schedules, and then sends a written report to the requesting physician. The general surgeon subsequently performs a biopsy and then routinely sees the patient once a year as follow-up. Subsequent visits provided by the surgeon should be billed as an established patient visit in the office or other outpatient setting, as appropriate. Other routine care continues to be followed by the family practice physician.

6.An internist examines a patient who has been under his care for some time, and diagnoses and diagnoses a thyroid mass. The internist sends the patient to a general surgeon for advice on management of the mass and related patient care. The general surgeon examines the patient, orders diagnostic tests, and suggests a needle biopsy
of the mass. The surgeon then schedules the procedure and sends a written report to the requesting physician. The general surgeon subsequently performs a thin needle
biopsy and then routinely sees the patient twice as follow-up for the mass. Subsequent visits provided by the surgeon should be billed as an established patient visit in the office or other or other outpatient setting, as appropriate. Other routine care continues to be followed by the internist.

7.A patient with underlying diabetes mellitus and renal insufficiency is seen in the emergency room for the evaluation of fever, cough and purulent sputum. Since it is
not clear whether the patient needs to be admitted, the emergency room physician requests an opinion by the on-call internist. The internist may bill a consultation regardless if the patient is discharged from the emergency room or whether the patient is admitted to the hospital as long as the criteria for consultation have been met. If the internist admits the patient to the hospital, he/she may bill either an initial inpatient consultation or initial hospital care code but not both for the same date of service.

I.Examples That Do Not Satisfy the Criteria for Consultations --

1.Standing orders in the medical record for consultations.

2.No order for a consultation.

3.No written report of a consultation