There are a different codes that can apply when billing referred consults depending on the circumstances (comprehensive, limited, repeat), but the rules are the same around when they can be billed. A consultation is billable when a patient has been referred because the referring physician is requesting the opinion of the consulting physician. In order to bill for this service, the consulting physician must complete an in depth evaluation of the patient with a written report back to the referring physician. The rules are clearly laid out in section 4.4 of the Governing Rules List.
Some of the most common misconceptions regarding consultations are:
1. The first time a specialist sees a patient they can bill a consultation. - This is not actually true. The patient must have been referred to them for their opinion. If there are multiple physicians working withing the same group, they do not each get to bill a consultation off of the same referral. There must be a new referral for each consult billed.
2. You can bill a new comprehensive consultation every 365 days. - This is definitely not the case, as per governing rule 4.4.6 in order to bill a repeat consultation a further request must be initiated by the referring physician. After 365 days the consulting physician CAN bill a comprehensive visit, but they cannot bill a comprehensive consultation without a new referral.
3. If a patient is "referred" to emergency from a clinic this is considered a consultation. - This is considered transfer of care. If a physician sees a patient in clinic and decides that patient would best be treated in emergency at the hospital and refers them to the hospital, this is not a request for an opinion. As per governing rule 4.4.1 consultations may not be claimed for transfer of care.