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? 


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.