Referral

Making a referral means Physician A is recommending a patient to Physician B or to another health care entity for services essential to the patient's overall care. When Physician B sees a patient at the request of the referring physician, Physician B bills the patient for a consultation. However, Medicare and other carriers do not consider referral to be a consultation. From the Medicare point of view, a referral means Physician A has transferred the care of the patient to Physician B, which for billing purposes is not the same as a consultation.

For Physician B to bill for a consultation, the patient must be referred by Physician A (or another physician) for opinion, advice, or management of a specific problem. A physician consultant (Physician B) can initiate diagnostic or therapeutic services at the same or a subsequent visit. Physician B should send a consultation letter to the referring physician (Physician A) documenting the request for consultation, the patient's history, the physical examination, an impression, recommendation, and any specific tests that were ordered for rendering the opinion. The consultation letter should clearly state that the patient was sent for consultation. The usual billing mistake made by consultants is that they use the term referral and consultation interchangeably and commonly state, in such a letter, “Thank you for referring this patient.” However, from the Medicare[Page 484] point of view this is incorrect. Physician B should state, “Thank you for sending this patient for consultation.” In addition, during a consultation the patient should see his or her own doctor (Physician A) after the services have been completed.

A referral initiated by a patient or family and not requested by Physician A cannot be billed as consultation. Physician B must bill such a visit either as “new patient” or as “established patient visit.” A new patient is defined as one who has not been seen by the physician or any other physician in the same group for at least 3 years.