STANDARD

Consultations must be requested (either orally or in writing) by the attending physician or other appropriate source, and such request must be documented in the patient’s medical record. The consultation must include a history, examination and determination with a written report, all of which is documented in the patient’s medical record. The physician consultant may initiate diagnostic and/or therapeutic services at the same or subsequent visit.

The specific criteria as stated by the American Medical Association in the 2005 CPT code book for consultation services include:

1. documentation in the patient record of an oral or written request and need for the consultation from the attending physician (or other appropriate source); and
2. documentation of history, exam and medical decision making defining the appropriate level of service, and
3. documentation in the patient record of communication to the requesting physician (or appropriate source), the consultant’s opinion and any services that were ordered or performed.

The AMA defines a consult as a physician service providing advice or an opinion regarding evaluation and management and/or treatment of a requesting physician’s patient. The 2005 CPT code book states, “A physician consultant may initiate diagnostic and/or therapeutic services.” See scenarios listed below.

Consultation with Initiation of Treatment

A consult occurs when one physician communicates to another, “Here is my patient; I am sending him/her to you for your expert advice and/or opinion as to how I can treat my patient.” In this situation, the consulting physician bills an initial consult, and the patient is typically returned to the requesting physician for follow up care. If the consultant’s findings and recommendations are beyond the scope of the requesting physician’s practice, and the requesting physician communicates to the consulting physician the transfer of care of the patient at this point, the consulting physician would report appropriate subsequent inpatient or outpatient services for follow up care, in addition to any additional procedures.

Scenario 1: A general surgeon is consulted by a patient’s internist for evaluation of a breast mass. At the initial consultation, the surgeon may determine that a biopsy is necessary to further evaluate the mass. CMS allows the surgeon to bill for the appropriate level initial consult, as well as the biopsy performed on the same day (whether in his office or at an ASC).

The surgeon documents the request for the consult from the requesting physician, history, exam and medical decision making elements, and any diagnostic or therapeutic procedures ordered or performed in evaluating the breast mass. He documents communication to the patient’s internist his findings of a diagnosis of fibrocystic breast disease which does not warrant further surgical care/intervention at this time. The patient returns to her internist for follow-up care.

Referral/Transfer of Care

A referral occurs when one physician communicates to another, “Here is my patient; I am sending him/her to you for treatment and/or procedures for a problem that is beyond the scope of my practice.” This is further defined in the Part B Answer Book Fax Alert, “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.” In this case, when the care of the patient has been transferred to the consulting physician at the time of the referral, the consulting physician initially reports the appropriate new or established patient visit and any additional diagnostic/therapeutic procedures. He will report appropriate subsequent in- or outpatient visit codes for follow-up care.

Scenario 2: The same clinical example, however, in this scenario the surgeon determines that further surgery is needed to remove the mass or breast. The consulting physician documents communication of his findings to the internist at which time he/she transfers the care of the patient over to the surgeon for further surgical care/intervention for the breast mass. (The patient record should contain discussion of coordination of care between the requesting physician and the consulting physician.) In this scenario, when the patient returns to see the surgeon for follow-up discussion of findings and surgical options, the consultant bills an established patient subsequent visit. Should this scenario occur in an inpatient setting, the consulting physician would bill the appropriate subsequent hospital care code.

Initiation of Treatment

There should be a distinct difference in documentation for when:

• a physician initiates treatment at the time of initial consultation or
• transfer of care occurs at the time of referral.

When the criteria are satisfied for reporting a consultation code AND initiation of treatment, the patient record should reflect the request and the need for the consult. If the consulting physician initiates treatment at the time of the consult, he may add a statement like, “I performed excisional biopsy while she was here for consultation, and am awaiting pending pathology report.”)

Should the requesting physician transfer the care of this patient to the consulting physician after the initial consult/initiation of care, return patient visits would be coded as appropriate subsequent in- or outpatient care.

Referral

A statement such as “Thank you for referring this patient to me for left inguinal hernia repair,” indicates the transfer of care occurred at the time the referral was made. The appropriate new or established patient visit code would be reported. Subsequent visits would be reported using the appropriate subsequent in-or outpatient visit codes.

Note:

Follow-up inpatient consultation codes (99262-99263) are only reported:

• when concluding initial consultative services.
• when subsequent requests are made by the attending physician for further consultative visits during the same inpatient stay.

The 2005 CPT manual states, “If the physician consultant has initiated treatment at the [time of the] initial consultation, and participates thereafter in the patient’s management, the codes for subsequent hospital care should be used (99231-99233).”

The four categories of consultations include:

• Office;
• Initial Inpatient;
• Follow up Inpatient; and
• Confirmatory

Addendum…

Consultations not requested by a physician are not coded using the initial consultation codes. These consults are coded using the confirmatory or office visit codes.

Teaching Physician Documentation

1. If a teaching physician is supervising a resident performing the consultation service, the written report should be signed by the teaching physician and a personal notation made on the report concerning the teaching physician’s participation in the three (3) key components of the consultation (i.e. history, physical examination and medical decision making).
2. The resident’s note should reflect that the teaching physician was present and participated in the key components of the consultation.

The chart below provides additional clarification on the distinction between “consult” and “referral.”

Consultation	Referral
A request for an opinion or advice from one physician by another physician, patient, relative of patient, or insurance company.	A transfer of all or part of the patient’s care from one physician to another.
Performed for a suspected problem.	Performed for a known problem.
The requesting physician will decide, after the consult, who will manage the patient’s care.	The patient’s care is transferred to the physician accepting the referral.
The consultant physician must submit a written report of the findings and opinion to the requesting physician and the patient’s medical record.	No report is required to be sent to the physician forwarding the referral, although it is often done as a courtesy.
The request and the need for the consult must be documented in the patient’s record.	Not applicable
The name and UPIN of the referring physician must be present on the CMS 1500 in items 17 and 17a.	Not applicable unless the referral is for diagnostic laboratory services, diagnostic radiology services or durable medical equipment.

As of January 1, 2010, CMS eliminated the payment of all CPT consultation codes (inpatient and outpatient codes) for various places of service except for telehealth consultation HCPCS G-codes.  Providers must bill the E/M code (other than a CPT consultation code) that describes the service they provide in order to be paid for the E/M service furnished.

REGULATORY REFERENCES

MLN Matters Number: SE1010, Effective Date: January 1, 2010