CODING COACH:Consult or Referral? You Be The Judge

Why This Topic Matters

Properly identifying consult versus referral encounters affects whether the visit is reported as a consultation or as another E/M service, which can change compliance risk and reimbursement. The article is relevant to practices that receive patient referrals from other physicians or nonphysician practitioners and need consistent documentation and audit readiness.

Article Sections

1. Know the 5 Rs

   Introduces a documentation framework used to evaluate consultation encounters and outlines the broad elements that should be present in the record.

2. A Request Comes In

   Discusses how to interpret the sending provider’s intent and the documentation clues that help distinguish a request for opinion from a transfer of care.

3. Not a consult

   Presents an example of a patient being sent within a specialty group and explains that the scenario is being evaluated as a non-consult visit type.

4. Yes, a consult

   Presents an example of a specialty opinion request and describes the broad documentation elements associated with a consultation scenario.

5. Problem

   Addresses practical challenges in tracking consultation documentation and mentions the use of internal processes to support compliance review.

6. Is the Opinion Documented?

   Focuses on verifying that the consultant’s assessment and treatment recommendations are recorded in the chart.

7. Did Your Doctor Report Back?

   Covers the need for evidence that the consulting physician communicated findings back to the requesting provider.