decisionhealth Newsletters, Answer Books - 2009 Issue 9 (September)
Consults, Visits, Referrals / Consult vs Visit - Medicare Carriers Manual
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Article Overview
This article reviews Medicare carrier guidance on distinguishing consultation services from visits and referrals. It uses illustrative scenarios to show the kinds of documentation and care relationships involved, and it is useful for coders, billers, auditors, and practice staff working with E/M services under Medicare guidance.
Why This Topic Matters
Correctly distinguishing consults from visits affects E/M reporting and documentation compliance under Medicare guidance. The article helps readers understand the scope of examples CMS uses when determining whether a service qualifies as a consultation.
Article Sections
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Examples That Meet the Criteria for Consultation Services
Illustrative scenarios showing circumstances CMS considers consistent with consultation service criteria. The section focuses on physician-to-physician requests, specialty evaluation, and follow-up context.
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Examples That Do Not Meet the Criteria for Consultation Services
Illustrative scenarios showing circumstances CMS does not treat as consultation services. The section highlights common documentation and referral patterns that fall outside consultation criteria.
What You Will Learn
- How Medicare carrier guidance frames consult-versus-visit distinctions
- What kinds of scenarios are presented as meeting consultation criteria
- What kinds of scenarios are presented as not meeting consultation criteria
- The role of documentation and inter-physician communication in consultation examples
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Practice administrators
- Auditors
- Physician office staff
Modifiers Discussed
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