What is the difference between a consult and a referral?

Many patients come to see endocrinologists upon the request of their primary care or other physicians. The reimbursement for a consult is more than a referral. Therefore, most cognitive specialists prefer to see new patients in consultation.

Sometimes, however, there is confusion regarding the difference between a consult and a referral.

A consultation is a rendering of advice or professional opinion, followed by a report of findings to the referring physician. A referral on the other hand is simply a request to assume care of a patient.

In order to bill for a consult, it is essential for that to be supported in the medical record. Besides the key components which are required for coding any visit, there must also be documentation of the four “Rs”:

Request – for the consultant to see the patient (in writing).
Reason – why consult is requested.
Report – submit report of recommendations back to requesting physician (in writing).
Return – the patient continues to see the requesting physician for follow up and ongoing care.

The consult request could be in a letter or on a form, or it could be a statement in the medical record, such as “will consult endocrinology.”

Sending a copy of the consult note meets requirements of submitting a report back to the requesting physician. However, I also include a cover letter summarizing my thoughts because my consult notes are often lengthy. Even though sending a cover letter is good for patient care and appreciated by colleagues, there is not a formal requirement for this according to the rules.

Seeing a patient in consultation does not prevent the consultant from ordering diagnostic studies or from seeing the patient in follow-up. In chronic diseases, such as diabetes or thyroid cancer, often our recommendations will include advising the patient to return to see us.

Consult requests are sometimes ambiguous. A request stating, “Refer to endocrinology for recommendations on osteoporosis,” is more than likely a consult, even despite the word “refer” being used. However, the following request, “Consult to assume management,” may be interpreted as a referral because it is a request to assume care.

When in doubt, we contact the requesting physician to clarify. We apologize for any inconvenience this causes. However, the reimbursement for doing the same work is less for a referral than a consult. More importantly, there may be problems if you are ever audited and the medical record does not support billing consultations.

The American Association of Clinical Endocrinologists offers courses for endocrinologists and their staff to learn more about coding. For more information: http://www.aace.com/meetings/CEC/index.php