Q: I know you’ve written about consultations before. However, I still find it very confusing as to how to differentiate between a consultation and a referral. I prepared the chart (below) in an attempt to compare a referral with a consultation. For purposes of this chart, I am asking mainly about office-based visits. I am a dermatologist and rarely go to an inpatient setting. So please answer my question about what is a consultation versus a referral with respect to the office setting. A: Your assumptions couldn’t be more incorrect, but I’m glad to have the opportunity to explain again why. Let’s review items 1 through 6 in the chart. 1. Suspected versus known problem. It’s really irrelevant whether or not the problem or skin condition has been diagnosed. It’s not at all uncommon for a primary care physician (PCP) — or other consult-seeking physician — to know the diagnosis yet seek treatment options and advice from a specialist. For example, a PCP may be treating a patient for acne or eczema with minimal results. He or she may ask the specialist, the dermatologist, to offer treatment suggestions or options. Sometimes, the PCP may just want clarification that a treatment is appropriate. Bottom line: Whether or not there’s a definitive diagnosis has nothing to do with differentiating a referral from a consultation. 2. Patient must return to the PCP for care versus the PCP transferring total care to the dermatologist. First, you must understand what transfer of care means. It doesn’t mean transfer of care for a certain medical condition; it means that the entire medical condition(s) that the patient is suffering from will be treated by the physician to whom care is transferred. Primary care physicians can’t and wouldn’t transfer the total care of a patient to a dermatologist. A transfer means that, for example, if the patient was suffering from diabetes and acne rosacea, the dermatologist would now be responsible for treating both the diabetes and the acne. Of course, that’s ridiculous and it’s why the transfer of care concept rarely, if ever, applies to dermatologists. CPT’s definition of a consultation doesn’t require that the patient return to the consult-seeking physician, nor does it prohibit the dermatologist from taking over the care and treatment of the dermatologic condition. It only states: “If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient’s condition, the follow-up consultation should not be used. In the office setting, the appropriate established patient code should be used.” Bottom line: It doesn’t matter who ultimately assumes the care of the patient’s dermatologic condition. The patient could return to the PCP or the dermatologist could inherit the patient long-term. 3. Written/oral request for opinion of specific reason versus appointment made for the purpose of providing treatment. One of the key elements in documentation of a consultation is that the medical record must state that the patient was sent by another physician who is asking for advice and opinion regarding a specific problem. So let’s clarify a few misnomers. a. You don’t need a written or oral request from the consult-seeking physician. Your chart note, however, must state that “the patient was sent by Dr. (indicate name of physician) for evaluation of (name specific problem).” Again, the problem or condition for which the PCP is asking advice or opinion could be an established diagnosis. It may be that the PCP simply wants input as to whether the treatment is appropriate. b. The dermatologist may initiate treatment at the time of the consultation visit, or he or she may just make recommendations to the PCP regarding suggested treatment and/or treatment options. CPT states, “A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.” Keep in mind that some managed care plans, which require care to be authorized by the PCP, may limit the consultation request/authorization to evaluation only (e.g., no treatment provided). However, this is inconsistent with CPT’s definition. Bottom line: The chart note needs to state who sent the patient and for what specific problem. Whether or not any treatment is initiated is irrelevant to meeting the criteria for a consultation. 4. Patient advised to follow-up with PCP versus patient advised to return for additional discussion. In order to charge a consultation ser-vice neither one of the two is required. The dermatologist may diagnose the problem and initiate treatment to resolve the problem entirely. So with respect to the problem for which the PCP sent the patient, the patient may not need to see either physician in the future. However, if the dermatologist must make an evaluation of the condition and render advice or an opinion regarding the diagnosis and treatment options, then the recommendations made by the dermatologist (e.g., consultant-specialist) must be sent formally to the consult-seeking physician. A letter is most common. Some providers have great dictated notes or electronic medical records that make it easy to send a copy of the progress note. The formal correspondence can be faxed, e-mailed or mailed in the traditional envelope. Bottom line: No follow-up is needed. A letter must be sent to the consult-seeking physician by the dermatologist regarding the findings of the visit and recommendations. 5. Final diagnosis is unknown versus final diagnosis is typically known at the time of referral. Whether the final diagnosis is unknown or known at the time of the consultation or even after the consultation has been completed is a non-issue. It’s not entirely uncommon for the final diagnosis to remain unknown. Some conditions are never definitively defined. The dermatologist may consider various differential diagnoses or establish some “rule out” conditions while treatment is initiated. In some unique cases, there may never be a final diagnosis. Bottom line:Whether or not this was a diagnosis at the time of the initiation of the consultation or after the consultation has been completed doesn’t matter. 6. Verbiage in letter to consult-seeking provider: “Thank you for asking me to consult on patient . . . .” versus “Thank you for referring this patient for condition . . . .” Either of the above “thank you” phrases is acceptable in a consultation letter. No auditor is going to deny the billing of a consultation based on the verbiage in the letter of consultation. Bottom line: The important factor is that there is a form of formal correspondence back to the consult-seeking provider. Billing for a Consultation Whenever you have questions regarding whether to code for a consultation or a referral, keep these bottom-line points in mind: 1. The dermatologist’s chart note must indicate that he or she received a request from an appropriate source and that the source requested the dermatologist’s advice and opinion regarding a specific dermatologic condition. 2. The dermatologist may initiate care, write prescriptions, perform surgical services or procedures and still bill a consultation code. 3. The dermatologist may continue to see the patient and care for the problem after the initial consultation has been completed. 4. The dermatologist must be able to demonstrate that he or she provided a formal, written report of the findings and recommendations to the consult-seeking provider.
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Differentiating Between Referrals and Consultations
Q: I know you’ve written about consultations before. However, I still find it very confusing as to how to differentiate between a consultation and a referral. I prepared the chart (below) in an attempt to compare a referral with a consultation. For purposes of this chart, I am asking mainly about office-based visits. I am a dermatologist and rarely go to an inpatient setting. So please answer my question about what is a consultation versus a referral with respect to the office setting. A: Your assumptions couldn’t be more incorrect, but I’m glad to have the opportunity to explain again why. Let’s review items 1 through 6 in the chart. 1. Suspected versus known problem. It’s really irrelevant whether or not the problem or skin condition has been diagnosed. It’s not at all uncommon for a primary care physician (PCP) — or other consult-seeking physician — to know the diagnosis yet seek treatment options and advice from a specialist. For example, a PCP may be treating a patient for acne or eczema with minimal results. He or she may ask the specialist, the dermatologist, to offer treatment suggestions or options. Sometimes, the PCP may just want clarification that a treatment is appropriate. Bottom line: Whether or not there’s a definitive diagnosis has nothing to do with differentiating a referral from a consultation. 2. Patient must return to the PCP for care versus the PCP transferring total care to the dermatologist. First, you must understand what transfer of care means. It doesn’t mean transfer of care for a certain medical condition; it means that the entire medical condition(s) that the patient is suffering from will be treated by the physician to whom care is transferred. Primary care physicians can’t and wouldn’t transfer the total care of a patient to a dermatologist. A transfer means that, for example, if the patient was suffering from diabetes and acne rosacea, the dermatologist would now be responsible for treating both the diabetes and the acne. Of course, that’s ridiculous and it’s why the transfer of care concept rarely, if ever, applies to dermatologists. CPT’s definition of a consultation doesn’t require that the patient return to the consult-seeking physician, nor does it prohibit the dermatologist from taking over the care and treatment of the dermatologic condition. It only states: “If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient’s condition, the follow-up consultation should not be used. In the office setting, the appropriate established patient code should be used.” Bottom line: It doesn’t matter who ultimately assumes the care of the patient’s dermatologic condition. The patient could return to the PCP or the dermatologist could inherit the patient long-term. 3. Written/oral request for opinion of specific reason versus appointment made for the purpose of providing treatment. One of the key elements in documentation of a consultation is that the medical record must state that the patient was sent by another physician who is asking for advice and opinion regarding a specific problem. So let’s clarify a few misnomers. a. You don’t need a written or oral request from the consult-seeking physician. Your chart note, however, must state that “the patient was sent by Dr. (indicate name of physician) for evaluation of (name specific problem).” Again, the problem or condition for which the PCP is asking advice or opinion could be an established diagnosis. It may be that the PCP simply wants input as to whether the treatment is appropriate. b. The dermatologist may initiate treatment at the time of the consultation visit, or he or she may just make recommendations to the PCP regarding suggested treatment and/or treatment options. CPT states, “A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.” Keep in mind that some managed care plans, which require care to be authorized by the PCP, may limit the consultation request/authorization to evaluation only (e.g., no treatment provided). However, this is inconsistent with CPT’s definition. Bottom line: The chart note needs to state who sent the patient and for what specific problem. Whether or not any treatment is initiated is irrelevant to meeting the criteria for a consultation. 4. Patient advised to follow-up with PCP versus patient advised to return for additional discussion. In order to charge a consultation ser-vice neither one of the two is required. The dermatologist may diagnose the problem and initiate treatment to resolve the problem entirely. So with respect to the problem for which the PCP sent the patient, the patient may not need to see either physician in the future. However, if the dermatologist must make an evaluation of the condition and render advice or an opinion regarding the diagnosis and treatment options, then the recommendations made by the dermatologist (e.g., consultant-specialist) must be sent formally to the consult-seeking physician. A letter is most common. Some providers have great dictated notes or electronic medical records that make it easy to send a copy of the progress note. The formal correspondence can be faxed, e-mailed or mailed in the traditional envelope. Bottom line: No follow-up is needed. A letter must be sent to the consult-seeking physician by the dermatologist regarding the findings of the visit and recommendations. 5. Final diagnosis is unknown versus final diagnosis is typically known at the time of referral. Whether the final diagnosis is unknown or known at the time of the consultation or even after the consultation has been completed is a non-issue. It’s not entirely uncommon for the final diagnosis to remain unknown. Some conditions are never definitively defined. The dermatologist may consider various differential diagnoses or establish some “rule out” conditions while treatment is initiated. In some unique cases, there may never be a final diagnosis. Bottom line:Whether or not this was a diagnosis at the time of the initiation of the consultation or after the consultation has been completed doesn’t matter. 6. Verbiage in letter to consult-seeking provider: “Thank you for asking me to consult on patient . . . .” versus “Thank you for referring this patient for condition . . . .” Either of the above “thank you” phrases is acceptable in a consultation letter. No auditor is going to deny the billing of a consultation based on the verbiage in the letter of consultation. Bottom line: The important factor is that there is a form of formal correspondence back to the consult-seeking provider. Billing for a Consultation Whenever you have questions regarding whether to code for a consultation or a referral, keep these bottom-line points in mind: 1. The dermatologist’s chart note must indicate that he or she received a request from an appropriate source and that the source requested the dermatologist’s advice and opinion regarding a specific dermatologic condition. 2. The dermatologist may initiate care, write prescriptions, perform surgical services or procedures and still bill a consultation code. 3. The dermatologist may continue to see the patient and care for the problem after the initial consultation has been completed. 4. The dermatologist must be able to demonstrate that he or she provided a formal, written report of the findings and recommendations to the consult-seeking provider.
Q: I know you’ve written about consultations before. However, I still find it very confusing as to how to differentiate between a consultation and a referral. I prepared the chart (below) in an attempt to compare a referral with a consultation. For purposes of this chart, I am asking mainly about office-based visits. I am a dermatologist and rarely go to an inpatient setting. So please answer my question about what is a consultation versus a referral with respect to the office setting. A: Your assumptions couldn’t be more incorrect, but I’m glad to have the opportunity to explain again why. Let’s review items 1 through 6 in the chart. 1. Suspected versus known problem. It’s really irrelevant whether or not the problem or skin condition has been diagnosed. It’s not at all uncommon for a primary care physician (PCP) — or other consult-seeking physician — to know the diagnosis yet seek treatment options and advice from a specialist. For example, a PCP may be treating a patient for acne or eczema with minimal results. He or she may ask the specialist, the dermatologist, to offer treatment suggestions or options. Sometimes, the PCP may just want clarification that a treatment is appropriate. Bottom line: Whether or not there’s a definitive diagnosis has nothing to do with differentiating a referral from a consultation. 2. Patient must return to the PCP for care versus the PCP transferring total care to the dermatologist. First, you must understand what transfer of care means. It doesn’t mean transfer of care for a certain medical condition; it means that the entire medical condition(s) that the patient is suffering from will be treated by the physician to whom care is transferred. Primary care physicians can’t and wouldn’t transfer the total care of a patient to a dermatologist. A transfer means that, for example, if the patient was suffering from diabetes and acne rosacea, the dermatologist would now be responsible for treating both the diabetes and the acne. Of course, that’s ridiculous and it’s why the transfer of care concept rarely, if ever, applies to dermatologists. CPT’s definition of a consultation doesn’t require that the patient return to the consult-seeking physician, nor does it prohibit the dermatologist from taking over the care and treatment of the dermatologic condition. It only states: “If subsequent to the completion of a consultation, the consultant assumes responsibility for management of a portion or all of the patient’s condition, the follow-up consultation should not be used. In the office setting, the appropriate established patient code should be used.” Bottom line: It doesn’t matter who ultimately assumes the care of the patient’s dermatologic condition. The patient could return to the PCP or the dermatologist could inherit the patient long-term. 3. Written/oral request for opinion of specific reason versus appointment made for the purpose of providing treatment. One of the key elements in documentation of a consultation is that the medical record must state that the patient was sent by another physician who is asking for advice and opinion regarding a specific problem. So let’s clarify a few misnomers. a. You don’t need a written or oral request from the consult-seeking physician. Your chart note, however, must state that “the patient was sent by Dr. (indicate name of physician) for evaluation of (name specific problem).” Again, the problem or condition for which the PCP is asking advice or opinion could be an established diagnosis. It may be that the PCP simply wants input as to whether the treatment is appropriate. b. The dermatologist may initiate treatment at the time of the consultation visit, or he or she may just make recommendations to the PCP regarding suggested treatment and/or treatment options. CPT states, “A physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.” Keep in mind that some managed care plans, which require care to be authorized by the PCP, may limit the consultation request/authorization to evaluation only (e.g., no treatment provided). However, this is inconsistent with CPT’s definition. Bottom line: The chart note needs to state who sent the patient and for what specific problem. Whether or not any treatment is initiated is irrelevant to meeting the criteria for a consultation. 4. Patient advised to follow-up with PCP versus patient advised to return for additional discussion. In order to charge a consultation ser-vice neither one of the two is required. The dermatologist may diagnose the problem and initiate treatment to resolve the problem entirely. So with respect to the problem for which the PCP sent the patient, the patient may not need to see either physician in the future. However, if the dermatologist must make an evaluation of the condition and render advice or an opinion regarding the diagnosis and treatment options, then the recommendations made by the dermatologist (e.g., consultant-specialist) must be sent formally to the consult-seeking physician. A letter is most common. Some providers have great dictated notes or electronic medical records that make it easy to send a copy of the progress note. The formal correspondence can be faxed, e-mailed or mailed in the traditional envelope. Bottom line: No follow-up is needed. A letter must be sent to the consult-seeking physician by the dermatologist regarding the findings of the visit and recommendations. 5. Final diagnosis is unknown versus final diagnosis is typically known at the time of referral. Whether the final diagnosis is unknown or known at the time of the consultation or even after the consultation has been completed is a non-issue. It’s not entirely uncommon for the final diagnosis to remain unknown. Some conditions are never definitively defined. The dermatologist may consider various differential diagnoses or establish some “rule out” conditions while treatment is initiated. In some unique cases, there may never be a final diagnosis. Bottom line:Whether or not this was a diagnosis at the time of the initiation of the consultation or after the consultation has been completed doesn’t matter. 6. Verbiage in letter to consult-seeking provider: “Thank you for asking me to consult on patient . . . .” versus “Thank you for referring this patient for condition . . . .” Either of the above “thank you” phrases is acceptable in a consultation letter. No auditor is going to deny the billing of a consultation based on the verbiage in the letter of consultation. Bottom line: The important factor is that there is a form of formal correspondence back to the consult-seeking provider. Billing for a Consultation Whenever you have questions regarding whether to code for a consultation or a referral, keep these bottom-line points in mind: 1. The dermatologist’s chart note must indicate that he or she received a request from an appropriate source and that the source requested the dermatologist’s advice and opinion regarding a specific dermatologic condition. 2. The dermatologist may initiate care, write prescriptions, perform surgical services or procedures and still bill a consultation code. 3. The dermatologist may continue to see the patient and care for the problem after the initial consultation has been completed. 4. The dermatologist must be able to demonstrate that he or she provided a formal, written report of the findings and recommendations to the consult-seeking provider.
