NAMAS Compliance Tip: Consultation or Transfer of Care, What are the Differences?

According to 2017 Current Procedural Terminology (CPT), a Consultation is a type of E&M service provided by a physician at the request of another physician or other appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient's entire care or for the care of a specific condition or problem. Consultations can be requested by a physician or other appropriate source (non physician practitioner, lawyer, or insurance company). Some third-party payers may restrict which "appropriate sources" are allowed to initiate a request for E&M services.Also, note that Medicare does not pay for consultations. A consultation initiated by a patient and/or family member is not reported using the consultation codes but may be reported using office visit (99201-99215), home visit (99341-99350), or domiciliary/rest home care (99324-99337 codes as appropriate.

Transfer of Care is the process whereby a physician who is providing management for some or all of a patient's problems relinquishes this responsibility to another physician who explicitly agrees to accept this responsibility, and who, from the initial encounter, is not providing consultative services. The physician transferring care is then no longer assuming primary responsibility for these problems, though he or she may continue providing care for other condition(s) when appropriate. Consultation codes should not be reported by the physician who has already agreed to accept transfer of care before the initial evaluation.

Prior to beginning an audit, ask for a list of providers with their respective specialty (i.e. PCP, dermatologist, urologist, etc.) and what department the provider is assigned to. As you audit consultation documentation, it is important to know if the referring provider is a primary care, emergency department or a specialty provider which will assist you to determine who will continue to treat the patient for the condition. It would be best to educate the providers to document who will be performing the follow up care for the condition.   Per consult guidelines, the consulting provider should state in their documentation a copy of the report will be sent to the referring provider.

Consult service - A primary care physician identifies a skin lesion during a preventative care visit and sends the patient for to a dermatologist for a consult to evaluate the lesion. The dermatologist determines the lesion is malignant and needs to be removed. The dermatologist performs the procedure to remove the lesion, writes his/her report and sends a copy to the primary care physician regarding the evaluation and treatment of the patient. The primary care physician resumes care of the patient in accordance with the dermatologist recommendations for follow up care.

Transfer of care - A patient is seen in the emergency department for knee pain. After the emergency department physician evaluates the patient and reviews the x-ray(s), he/she refers the patient to an orthopedic physician for further care.

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