The underlying difference between a consultation and a referral is the intent of the visit. If the requesting provider expects you to provide only your opinion on the best course of treatment for the condition, it's a considered a Consult (even if you prescribe medication). If, on the other hand, the requesting provider knows the patient's condition will require treatment beyond his or her scope of care and expects you to take over treatment of that condition, it's a Referral.
You're doing a consultation if:
- Another provider or appropriate source requests your services,
- The reason for the request is documented and
- You provide a report on your findings the requesting provider.
It is recommended that the clinicians avoid words like "referral" or "referred by" when documenting the request for consultation services. Some payers may deny consultation codes based on the use of these words or phrases.
The recommended language for consultations is "The patient was seen in consultation at the request of Dr. XXX for (what the provider is rendering an opining on)".
- The request as well as the subsequent opinion must be documented in the medical record.
- In an academic setting, a consult may be requested by a faculty physician or a community-based physician.
- If the consultant assumes care of patient, do not use consultation codes for subsequent visits.