Billing: Is it a consultation or transfer of care?

Billing and documentation continue to be problematic for providers even though Current Procedural
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Billing and documentation remain problematic for providers, even with the Current Procedural Terminology (CPT®) defining 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 a physician or other appropriate source, to recommend care for a specific condition or problem or to determine whether the referred physician will accept responsibility for ongoing management of the patients’ entire care or for 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 has not provided consultative services from the initial encounter, and relinquishes responsibility.

The physician or other qualified health care 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 made after the initial evaluation, it is appropriate to report the evaluation 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, according to the Division of Workers’ Compensation (DOWC) Rule 18-4(B)(5):

  • The physician requesting the opinion must be identified in the billing provider’s report
  • The report’s documentation must support the need for a consultant’s opinion
  • The report must be 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.

Pinnacol Assurance periodically reviews billing for consultation codes so the necessary documentation requirements are met.

Questions? Please contact us at or 303.361.4940.

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