Consults in a group

February 23rd, 2009 - Codapedia Editor
Categories:   Coding   Evaluation & Management (E/M)  

Can one physician request a consult from another physician in the same group?  

Sometimes.  (Don't we long for yes or no answers?)

One physician can request a consult from another physician in the same group, of the same or different specialty, when the conditions of a consult are met, and the service is not a transfer of care.  Notice that specialty designation is not a condition.  A consult requires a request for an opinion, advice, or evaluation.  The intent is to get the expertise of the other clinician about a specific problem or condition.  Consults require a specific reason.  And of course, the report.

A transfer of care occurs when the physician transfers care to the other physician for the treatment of that condition.

Let's use an Orthopedic example.

Ortho Doctor A is seeing a patient for joint pain and osteoarthritis.  Doctor A sees the patient on an ongoing basis and plans to continue treating the patient.  At one of the visits, the patient complains of increased back pain. After imaging, Doctor A asks Doctor B (also an Orthopedist, same practice, but with a subspecialty in spine) for her opinion about treatment options.  Doctor A plans to continue seeing and treating the patient after Doctor B's assessment.  The visit with Doctor B. would be a consult.  

Let's use another example.  Doctor A is seeing a patient in consultation for assessment of back pain, at the request of the PCP.  After assessing the patient, Doctor A determines that the patient should be seen by Doctor B (also an Orthopedist, same practice, with a subspecialty in spine) and suggests that the patient make an appointment with Doctor B.  Doctor A does not plan to continue to see or treat the patient, because Doctor B is the more appropriate physican for the patient's condition.  The visit with Doctor B is an established patient visit.   Since they are physicians in the same group, same specialty, the visit is not new.  There is no request for an opinion--the care is transferred.

Do not use consults for supervision of Non-Physician Practitioners. 

When a patient is sent to a group practice for an opinion from their PCP, take care to get the patient to the right physician the first time.

Here is all that the Medicare Claims Processing Manual says about consults in a group:

E.  Consultations Requested by Members of Same Group
Carriers pay for a consultation if one physician or qualified NPP in a group practice
requests a consultation from another physician in the same group practice when the
consulting physician or qualified NPP has expertise in a specific medical area beyond the
requesting professional’s knowledge.  A consultation service shall not be reported on
every patient as a routine practice between physicians and qualified NPPs within a group
practice setting.



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