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?
Documentation requirements for consultations
To bill for consultations, according to the Division of Workers’ Compensation (DOWC) Rule 18-4(B)(5):
Documentation examples
These examples do not meet the requirement for a consultation request or report:
This example of documentation supports a consultation code:
Pinnacol Assurance periodically reviews billing for consultation codes so the necessary documentation requirements are met.
Questions? Please contact us at billingsuccess@pinnacol.com or 303.361.4940.