Legal Tips
Provided by Carolyn Buppert, MSN, JD, ANP

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 complaint.

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 Carolyn Buppert.

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 21403.

A companion newsletter, The Gold Sheet, addresses malpractice avoidance and quality for NPs. The Gold Sheet is also $25 per year.

Updated June 14, 1999


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