Consultation and Referrals

Consultation services are predominantly billed by specialty physicians. Developed by the AMA Current Procedural Terminology (CPT) Editorial Panel, current physician visits and consultation codes are determined based on coding guidelines and criteria.

Coding for a consultation versus a referral continues to be a topic of confusion but there are simple differences between the two services. A consultation is a request by a qualified provider for the advice or opinion of a physician regarding the evaluation and/or management of a specific problem. A referral is the transfer of care from one physician to a second physician when the second takes over responsibility for treatment of the patient. Keep in mind, not every referral of a patient to a specialist constitutes a consultation service; instead, a referral may constitute a “transfer of care.”

The CMS states, “The intent of a consultation service is that a physician is asking another physician for advice, an opinion, recommendation, suggestion, direction, counsel, etc., in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.” On January 1, 2010 Medicare stop accepting consultations codes for office and outpatient services (99241–99245) and inpatient services (99251– 99255). Some private carriers are still accepting the consultation codes and it is important for practices to verify with the carrier on their billing guidelines.

There are certain requirements that must be met in order to qualify a visit as a consultation. These requirements include, requesting physician must document the reason or need for the consultative service, request services of consulting physician, the consulting physician must render an opinion, and send a report to the requesting physician. One way to remember these requirements is the rule of three R’s: request, render opinion, and response/report. The following chart summarizes the difference between a consult and a referral.

Consultation Referral
Request “Please see patient for a consult”
“Consulting services requested” - should be in writing
“Patient has been referred by…”
Problem Suspected diagnosis - consulting physician unsure of condition or assumption of management Identified problem
Treatment Undetermined or possibly known Known
Requesting Physician Decides which physician will administer care Uncertain of diagnosis at time of consult Oversees and manages care
Report Written report to requesting physician Written report to requesting physician is optional
CPT Code Consultation codes New or established patient codes

Consultation Forms

The ACR has developed forms for physicians to utilize in their practice to guarantee proper documentation for consultations. These forms can be used in patient records to show medical necessity. All files are Word document to allow you to customize them for your practice.