Inter-practice consultations: Avoid transfer of care pitfalls

Why This Topic Matters

Billing choices for specialist referrals can affect claim accuracy, audit risk, and payer payment decisions. Understanding the general distinctions discussed in the article helps practices evaluate whether a referral scenario is likely to support consultation billing or another type of eye exam billing.

Article Sections

1. Inter-practice consultation scenarios

   Overview of referral relationships within ophthalmology practices and between optometrists and ophthalmologists. Introduces the general issue of consultation billing versus transfer of care.

2. Auditors on the lookout

   Discussion of documentation review, payer scrutiny, and the role of records from both the requesting and consulting providers. Covers how audit concerns affect these referral scenarios.

3. Rule of thumb

   Broad guidance on when referral patterns are viewed as transfers of care and how that affects consultation billing in ophthalmology settings. Also notes an alternative eye-exam billing pathway and payer handling of subspecialty consults.

4. Specialists, sub-specialists and board certification

   Explains how payer recognition of specialties and subspecialties can affect consultation claims. Mentions the potential need for appeals and the possibility of payer-specific modifiers.