College of Medicine Office of Compliance, Gainesville, Florida
Consultation vs. a Visit
& Documenting a Consultation
What is the difference?
The yardstick for a consultation is that one physician requests the opinion or advice another physician regarding the management of a specific problem. The first visit is billed as a consultation (CPT codes 99241-99255) and subsequent visits (not performed to complete the initial consultation) to initiate or continue management for either a part or all of the patient's condition, are reported as established patient office visit or subsequent hospital care. A physician consultant may initiate diagnostic and/or therapeutic services at an initial or subsequent visit.
On the other hand, code a new or established patient visit when a transfer of care is expected. The referring physician transfers the responsibility for the patient's complete care to the receiving physician at the time of referral. The receiving physician would report a new or established patient visit depending on the situation and setting.
What is the required support for a consultation?
All three of the CPT E/M key components - history, exam and medical decision making, are required to support the level of service for a consultation. Alternatively, the level of service may be determined on the basis of time, when counseling and/or coordination of care dominates (more than 50%) the physician/patient and/or family encounter (face to face time in the office or other outpatient setting, or floor/unit time in the hospital.) The extent of counseling and/or coordination of care must be documented in the medical record. The REQUEST - There must be a request for a consultation from an appropriate source and the need for a consultation must be documented in the medical record. The patient may neither be self-referred, nor may the requesting physician simply suggest a physician's name to the patient. When the medical record is shared between the referring physician and the consultant, the request is usually found in the requesting physician's progress note, an order in the medical record, or a specific written request for the consultation. There is an official "Consultation Request" form available here at the Health Center (Form 15-0305-3). This consultation form is not required, but may serve as a convenient tool. Outpatient documentation may be a specific written request for the consultation from the requesting physician, or the consultant's record should make a specific reference to the request (this may be included in the dictation.) The REPORT - the consultant prepares a written report of his/her findings, recommendations for treatment, and any therapeutic interventions that have been planned or have begun, and the report is provided to the referring physician.
Also Worth Mentioning
Florida Medicaid and other payors will 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 of the requirements for use of the CPT consultation codes are met. Just be sure that the consultation is medically necessary.
Pre-operative consultations for a new or established patient performed by any physician at the request of a surgeon qualify as "consultations" as long as all of the requirements for billing the consultation codes are met.
As a general rule, the continuing management of the patient's problem in subsequent visits should be billed as a return patient visit.
The Health Care Financing Administration issued the following specialty specific examples in August, 1999
(excerpt only, bold and underlines added for emphasis):
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 subsequently 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 a 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 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 outpatient setting, as appropriate. Other routine care continues to be followed by the internist.
7. A patient with underling 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.
Examples That Do Not Satisfy the Criteria for Consultations
1. Standing orders in the medical record for consultations.
2.No order for a consultation. [ Editorial Note: there must be written documentation in the medical record identifying the requesting physician and medical necessity. Such support may be from the requesting physician, or the consulting physician- in the report to the referring physician, in the dictation, consultation form or in the notes.]
3. No written report of a consultation.
4. After hours, an internist receives a call from her patient about a complaint of abdominal pain. The internist believes this requires immediate evaluation and advises the patient to go to the emergency room where she meets the patient and evaluates him. The emergency room physician does not see the patient. The internist should bill for the appropriate level of emergency department service, or if the patient is admitted to the hospital she would bill this visit as an inpatient admission.
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This page created August 24, 1999. Modified 03/02/2012
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