new patient consultation and new patient referral - what is the difference

It is also important to understand the difference between a new patient Consultation and
a New Patient Referral.

The need for a physician to request advice or expert opinion from a colleague, in the form of a professional consultation, is almost as old as medicine itself. However, physicians must be aware that there have been “clarifications” in the CPT guidelines distinguishing a Consultation (99241 – 99245), versus a New Patient Referral (99201 – 99205). For purposes of CPT, a consultation is defined as a type of service provided by a physician whose opinion or advice regarding evaluation and / or management of a specific problem is requested by another physician or other appropriate source. It appears there had been confusion in reporting consultative services beginning with the terms used to describe the service requested. The terms consultation and referral were mistakenly interchanged. When a physician refers a patient to another physician, it is not automatically a consultation. The revised Medicare Claims Processing Manual, effective Jan 1, 06, listed clarifications in Medicare rules in distinguishing a Consultation verses a New Patient Referral. The latter generally pays a
lower fee. Historically, physicians have known that in reporting a consultation service, the three R’s must be documented: Request, Render, and Report. Starting in 2006, CPT requirements have included one more R requirement: a Reason. There must be a request for consulting services from another physician or health care provider, the suspected or known diagnosis requires determination by a specialist who renders his / her opinion, the referring physician and consultant specifies a reason for the consultation, the treatment is undetermined or may be known, and a written report to the
requesting physician or referring source reiterating the reason for consultation plus the findings and opinions must be forwarded by the consultant. In most cases, a consultation is a one – time visit. A New Patient Referral usually has an identified problem which requires a specialist to provide care, and does not require that a written report be sent to the requesting physician or health care provider.


The policy changes or clarifications also state that a transfer of care occurs when a physician requests another doctor to assume the care of the patient. Ongoing management of the patient by the consultant physician cannot be reported using a consultation service code. Therefore, a referral for evaluation and management (E/M) cannot be considered a consultation because there has been a transfer of care. There also has been concern regarding language that the consulting physician must document the request and reason for the consultation in the patient’s medical record. Without that
documentation, the CPT code for a consultation could not be use. However, according the the E/M documentation guidelines, the consulting physician is not required to confirm that the requesting physician document his / her request. The documentation criteria for a consultation service requires that the requesting physician and consulting physician both document the request for consultation in their medical records, but each physician is required to keep their own accurate records and code accordingly. In the revised Medicare Claims Processing Manual, the section which discusses consultation followed by treatment, there are also rules governing those occasions when it may be necessary for the consulting physician to assume ongoing care of the patient. It should be
emphasized that the above guidelines differentiating a Consultation from a New Patient Referral apply primarily to Medicare patients. Currently it appears that non – Medicare payers have not yet implemented these regulations.