Health Information Management

Consultation v. visit: Know the difference

HIM-HIPAA Insider, May 18, 2004

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A consultation is a type of E/M service provided when one physician or appropriate nonphysician practitioner requests that another practitioner provide his or her opinion or advice regarding evaluation or management of a specific problem. The request for consultation can be verbal or in writing, but must be documented in the patient's medical record.

The consulting physician must provide a written report that becomes part of the medical record and a copy must be sent to the requesting physician. As with all documentation, this report must also include the date of the consultation. If the consultation is initiated and the patient wants a second opinion, the consultation E/M codes should not be billed. Consultations do not have a designation of "new" or "established patient," but are designated as either inpatient or outpatient.

Consultations are distinguishable from visits. Medicare pays for consultations regardless of any treatment initiated by the consultant, unless a transfer of care occurs. 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.

Examples that do not satisfy the criteria for consultations include the following:

  • Standing orders in the medical record for consultations
  • No order written for a consultation
  • No written report of a consultation
  • After hours, an attending physician sends her patient to the emergency room where she meets the patient and performs an E/M service. The emergency room physician does not see the patient. The attending physician should bill the appropriate level of emergency department service and not a consultation.

This week's excerpt is adapted from the "Compliance Troubleshooter: Tackling the top 10 compliance challenges." Click here to order or learn more.


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