The intent of a consultation is that a physician, qualified nonphysician practitioner (NPP), or other appropriate source is asking another physician or qualified NPP for advice, opinion, a recommendation, suggestion, direction, or counsel, etc. in evaluating or treating a patient because that individual has expertise in a specific medical area beyond the requesting professional’s knowledge.

In order to submit for a consultation service, the following criteria must be met:

• Request for consultation
  • A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care in the patient’s medical record
  • A consultation request by the requestor may be written on a physician order form in a shared medical record
  • A consultation request may be verbal; however, the verbal interaction identifying the request and reason for a consult must be documented in the patient’s medical record by the requesting physician or qualified NPP and also by the consultant physician or qualified NPP in the patient’s medical record
    
• Written report of consultation findings
  • The consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the requesting physician
  • The consultant’s written report may be part of a common medical record or in a separate letter to the requesting physician or qualified NPP and readily available

A physician or qualified NPP consultant may initiate diagnostic services and treatment at the initial consultation service or subsequent visit. Ongoing management, following the initial consultation service by the consultant physician, shall not be submitted with consultation service codes. These services shall be submitted as subsequent visits for the appropriate place of service and level of service. Payment for a consultation service shall be made regardless of treatment initiation unless a transfer of care occurs.

Transfer of Care
A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition.

When this transfer of care is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating this patient for the condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record or plan of care.

In a transfer of care the receiving physician or qualified NPP would submit the appropriate new or established patient visit code according to the place of service and level of service performed and shall not submit a consultation service.

Consultation Examples
In the examples below, it is assumed that all other consultation service requirements are met. Criteria for consultation services shall always include a request and a written report in the medical record as described above.

Example 1:
The internist identifies a questionable skin lesion and asks a dermatologist to evaluate the lesion. The dermatologist examines the patient and decides the lesion is malignant and needs to be removed. The dermatologist removes the lesion. The dermatologist dictates and forwards a report to the internist regarding the evaluation and treatment of the patient. The internist resumes care of the patient and continues surveillance of the skin on the advice of the dermatologist.

Example 2:
A family practice physician diagnoses a new onset of atrial fibrillation. The family practitioner sends the patient to a cardiologist for advice on the patient’s care and management. The cardiologist suggests a cardiac catheterization which he schedules and performs. The cardiologist sends a written report to the requesting physician. The cardiologist subsequently periodically sees the patient once a year for follow-up care. Following the advice and intervention by the cardiologist the family practice physician resumes the general medical care of the patient.

The subsequent visits provided by the cardiologist should be submitted as an established patient E/M visit in the office or other outpatient setting, as appropriate.

Example 3:
A family practice physician examines a female patient and diagnoses a breast mass. The family practitioner sends the patient to a general surgeon for advice and management of the mass. The general surgeon recommends a breast biopsy, which he schedules and performs. The general surgeon sends a written report to the requesting physician. He periodically sees the patient once a year as follow-up. Following the advice and intervention by the surgeon, the family practice physician resumes the general medical care of the patient.

Example 4:
A surgeon removes a malignant tumor and requests a consult from a radiation oncologist to determine what kind of adjunctive therapy is needed if any. The surgeon continues to observe the patient post-operatively. The radiation oncologist evaluates the patient and determines a course of treatment. A report is sent back to the surgeon.

Example 5:
A patient has an established diagnosis of GERD that is being treated by an internist. The patient calls the internist complaining of intense heartburn. The internist sends the patient to a gastroenterologist for evaluation and treatment. The patient returns to the internist after treatment of the GERD for general care but decides to see the gastroenterologist for the chronic diagnosis of GERD. A report is sent back to the internist.

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