One of the most troublesome coding decisions is determining whether a visit is a consultation or a referral. To avoid the hassle of incorrect coding, one must first understand the difference between a consultation and a referral.
A consultation is a rendering of advice, or professional opinion, followed by a report of any findings to the referring physician. This visit typically results in the patient returning to the primary care physician (PCP) who initiated care. If, following the consultation, the consulting physician decides to treat the patient, he or she may bill the first visit as a consult. Any visits after the original consultation should be billed as an established patient.
Conversely, a referral is a request to see a certain type of physician; it most likely is the result of insurance requirements for seeing a specialist. This visit must be billed as a new patient visit. For example, when a patient has an HMO plan, he or she cannot see any other physicians until the PCP has been seen. The PCP then acts as a gatekeeper for the patient’s medical care and provides the referrals needed to see other physicians.
Recently, the number of practices being audited for their consultation visits has been on the rise. As a result of these audits, practices are being fined for not having enough documentation to support the merit of coding the visit as a consultation, rather than a new patient visit.
“While the rise of audits may not be pleasant news, the ACR always offers members accurate and up-to-date information on coding guidelines,” says ACR professional coder Melesia Tillman, CPC, CCP, of recent inquires into the auditing process.
To help you document consults, the ACR provides template letters (download them at www.rheumatology.org under the “Practice Support” menu).