Part B Coding Coach: Consult or Referral? You Be the Judge

Why This Topic Matters

Consultation claims are closely reviewed, and the distinction between a consult and a referral can affect whether a claim is supported. Knowing the documentation themes discussed here can help practices reduce denials, improve compliance, and better align physician documentation with billing expectations.

Article Sections

1. Know the 5 Rs

   Introduces a framework for evaluating consultation documentation and the broader issues Medicare reviews on consult claims.

2. A Request Comes In

   Explains how to identify the type of request being made when one provider sends a patient to another and how that affects claim classification.

3. Not a consult

   Presents a scenario used to distinguish a transfer-of-care situation from a consultation in a specialty practice setting.

4. Yes, a consult

   Presents a contrasting scenario used to illustrate when a request for expert opinion may support consult documentation.

5. Is the Opinion Documented?

   Reviews the need for the consulting physician to document an opinion and related treatment recommendations in the record.

6. Did Your Doctor Report Back?

   Covers the importance of documenting communication back to the requesting physician as part of the consult record.