Know the difference between a consultation and a referral.
NPs need to know the difference between a consultation and a referral for
treatment, when ordering and when carrying out consultations or referrals.
A consultation is a request for opinion or advice, so that the reguestor can
manage the patient. A consultation is billed under one of the consultation
codes listed in Physicians' Current Procedural Terminology (CPT)
(99241-99245 for outpatient of office consultations). If the NP is the
consultant, the NP should document the request for a consultation, the reason
for the consult, and the NP's evaluation and recommendations.
Example: "Ms. Jones has been referred by Dr. Smith for consultation regarding
vaginal candidiasis non-responsive to treatment in the past six months."
Document the evaluation and recommendations for how Dr. Smith should deal
with the problem. Bill a consultation code. If the patient returns to the
consultant's office for follow-up, the follow-up visit should be billed using
the office visit codes for established patients (99211-99215).
When an NP requests a consultation from another provider, the NP should
request "consultation" on the referral form, rather than "referring Ms. Jones
for evaluation of candidiasis."
A referral is made when the referring provider wants to turn the management
of the patient over to the referred-to provider, at least for the current
When an NP refers a patient, the NP should state on the referral form that
the NP is "referring the patient for evaluation and treatment." The
referred-to provider will bill an evaluation and management code, rather than
a consultation code.
When patients are referred to an NP, the NP should bill the first visit as an
office visit for evaluation and management for a new patient (99201-99205) if
the patient has not been seen by the NP or a member of the NP's group in the
past three years. NPs should bill follow-up visits using the codes for
established patients, office visits (99211-99215).
This tip is excerpted from The Green Sheet, a newsletter on compensation and
reimbursement for nurse practitioners, published monthly by the Law Office of
Subscriptions: $25 per year (12 issues), mailed first class. To receive The
Green Sheet every month, mail your name, address and a check for $25 to Law
Offices of Carolyn Buppert, 1419 Forest Drive, Suite 205, Annapolis, MD
A companion newsletter, The Gold Sheet, addresses malpractice avoidance and
quality for NPs. The Gold Sheet is also $25 per year.