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Ask the expert: What constitutes a consult?

Hospitalist Leadership Connection, November 2, 2010

A consult is not a referral. There is a big difference between the two terms, and it is reflected in coding and subsequent billing. Medicare has rules concerning the definitions for “consultation” and “referral.” To qualify as a consultation, three Rs must be present:

• Request: An initiating (or requesting) physician makes a written request for a consultation and documents the need for a consultation in a patient’s medical record. In an inpatient setting, this is not usually a problem. The written order, or a consultation request form from a ward secretary, is sufficient, and progress notes usually reflect the need.
• Rendered opinion: The consulting physician evaluates the patient and renders a written opinion in the chart. This does not preclude the consulting physician from calling the initiating physician back, which is an excellent routine to keep the initiating physician relationship strong, but a written opinion must be in the medical record.
• Report back to requesting the physician: The consulting physician provides the initiating physician with a written report. The initiating physician can now make an informed decision as to appropriate treatment. The initiating physician may follow or ignore the recommended treatment. The initiating physician or the consultant may provide the treatment.

If the initiating physician requests the services of the consultant, then treat the patient (after the consulting physician has completed the consultation, which can be coded and billed separately), and the consultant assumes responsibility for the complete care of the patient, it becomes a referral. With regard to a consultation followed by a treatment, payment for a consultation can be made regardless of which doctor initiates treatment unless a transfer of care occurs. Transfer of care means a referring physician transfers responsibility for the patient’s complete care at the time of referral.

The above excerpt is adapted from The Surgical Hospitalist Program Management Guide: Tools and Strategies for Executives and Physicians, by John Nelson, MD, FACP; John Maa, MD, FACS; and foreword by Robert M. Wachter, MD, published by HCPro, Inc. Download a free sample chapter online at www.HCMarketplace.com.
 

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