When can I Bill for a Consult E/M Code?

by 
November 30th, 2016

Question: 

We get lots of physician referrals. When we do, we bill a consult code. AND someone told one of our doctors that when there is a referral but it’s not on our referral pad, we can’t bill the consult code. Do you know anything about this? 

Answer:

Unfortunately true referrals must be coded as an ordinary office visit E/M. Consultation codes are different from other primary E/M services in that there must be:

  1. A written request from an appropriate source. According to CPT guidelines, an appropriate consultation source includes a physician assistant, nurse practitioner, doctor of chiropractic, physical therapist, occupational therapist, speech language pathologist, psychologist, social worker, lawyer, or insurance company.

  2. A written report that is sent back to the requester. This extra work is the reason that consultation codes have a higher value than office/outpatient E/M codes. The written request must be only asking for your expert opinion, not a referral to you to begin care. That would just be coded as an ordinary outpatient E/M code. It must be clear that some other source just wants you to examine the patient and send him/her right back to them with a nice report. After the source reviews your report, he could then refer the patient and then care would begin as usual. The next E/M service provided would just be office/outpatient.

When can I Bill for a Consult E/M Code?. (2016, November 30). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/when-can-i-bill-for-a-consult-e-m-code-34789.html

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