Tips for Billing Success: Is it a consultation or transfer of care?

Billing and documentation continue to be problematic for providers even though Current Procedural Terminology (CPT) specifically defines consultation codes.

Differentiation between consultation and transfer of care

CPT defines a consultation as a type of evaluation and management service provided at the request of another physician or appropriate source to recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patients’ entire care or a specific condition or problem.Transfer of care occurs when a physician or other qualified professional providing management for some or all of a patient’s problems relinquish responsibility and who, from the initial encounter, is not providing consultative services.The physician or another qualified healthcare professional who agrees to accept transfer of care before an initial evaluation should not report consultation codes. If the decision to accept transfer of care can only be after the initial evaluation, it is appropriate to report the visits as a consultation.

When determining if a consultation is appropriate, review the request to determine what the requesting physician wants. Is the request for an opinion or is the provider transferring care?

  • "I need your advice (opinion) on how I can repair my patient’s broken leg." (consult)
  • "I’m sending my patient with a broken leg to you for surgery." (transfer of care/referral)

Documentation requirements for consultations

To bill for consultations, the Division of Workers’ Compensation (DOWC) Rule 18-5(I) (6)state the following criteria be documented in the billing provider’s report:

  • The physician requesting the opinion is identified.
  • The report documentation supports the need for a consultant’s opinion.
  • The report was sent to the requesting provider (by copy or written directly to the requesting provider).

Documentation examples

These examples do not meet the requirement for a consultation request or report:

  • Patient sent to Dr. Smith for consultation regarding a leg injury. Was the patient sent for an opinion on how to treat or was the patient transferred for care?
  • Thank you for your referral. Referring a patient to a specialist for care is not a consultation; it is a transfer of care.

This example of documentation supports a consultation code:

  • We discussed conservative care and operative interventions. The patient would like to proceed with surgery. A consultation was necessary to determine whether to accept responsibility for ongoing management.
Reference

Rule 18