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Family Practice Coding Alert

Gain Accurate Reimbursement by Distinguishing Between Consultations and Referrals

Correct use of consultation as opposed to referral can have significant impact on physician reimbursement. Unfortunately, these terms often are used interchangeably, resulting in confusion, claim denials and lost revenue.
Family physicians (FPs) find themselves on both sides of the consultation and referral equation. Many times, they act as the requesting physician, asking other specialists for advice or care for their patients. In other situations, medical colleagues seek the FPs opinion on conditions and treatment alternatives.

In either role, it is important for coding professionals to recognize that a consultation occurs when one physician requests the opinion or advice from another specialist regarding a specific aspect of patient care, while a referral entails turning the patients care over to the specialist.

According to Brett Baker, senior associate for regulatory affairs for the American College of Physicians-American Society of Internal Medicine (ACP-ASIM), HCFA recently updated and clarified its guidelines to resolve the confusion surrounding these terms (Section 15506 of the Medicare Carriers Manual [MCM]). This takes on significant importance when you recognize that a consultation carries a much higher relative value unit (RVU) than a referral does, he points out. Consultations are billed with CPT codes 99241-99275, while referrals are reported with office visit or hospital inpatient codes.

Sample RVU and Payment Comparison

Total RVUs Payment (national average)
Office visit codes
99213 1.32 $50.50
99215 3.06 $117.08

Consultation codes
99243 3.09 $118.22
99245 5.73 $219.23

What Is a Referral?

A referral is the simpler of the two concepts and has fewer requirements guiding its use, Baker says. Usually, a referral occurs when the family physician sends the patient to a specialist with the intention that the specialist assumes treatment for the patient for the condition specified and performs all followup care.

For example, a 35-year-old woman who has a history of diabetes becomes pregnant. The family physician requests that an obstetrician (ob) who has experience managing pregnancies with this type of complication assume care. The ob would provide antepartum, labor and delivery, and postpartum care to the patient. A second example may involve a teen-age patient who suffers from severe acne. The FP may refer the adolescent to a dermatologist for treatment of that specific condition.

A reverse situation may occur when a patient has selected a gynecologist as her primary care physician, as some health plans allow. However, this patient develops a mild but persistent skin rash, and the gynecologist refers her to a family physician for care. The FP would bill for an office visit, new patient (evaluation and management codes 99201-99205) or, if the patient had been seen by that physician or another family physician who belongs to the same group practice within the previous three years, with an [...]