Is it a consultation? Or is it a referral?

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.