decisionhealth Newsletters, Answer Books - 2008 Issue 5 (May)
Answer_Book / Consults,_Visits,_Referrals / What_doesn’t_constitute_a_consult
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Article Overview
This article explains the kinds of scenarios CMS does not consider to be consultations in the consults, visits, and referrals context. It is aimed at coding and billing staff who need to recognize when documentation or referral circumstances do not support a consult classification and instead point to another type of encounter. The content focuses on high-level consult criteria, documentation expectations, and Medicare-related caveats without providing code-specific instructions.
Why This Topic Matters
Correctly distinguishing consultations from other encounters affects claim classification and compliance in office, specialist, and emergency department follow-up scenarios. Understanding these distinctions helps reduce misbilling when the referral source, order, or written report requirements are not present.
What You Will Learn
- Which general situations do not satisfy consult criteria
- What documentation elements are commonly associated with a consultation
- How consult-related scenarios differ from other visit pathways in broad terms
- Why Medicare-related consult expectations matter in referral situations
Who Should Read This
- Medical coders
- Billing staff
- Revenue cycle professionals
- Compliance staff
- Physician practice administrators
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