Compliance: Prove Consults With A Written Request

Why This Topic Matters

Consult documentation can affect whether a service is supported in the record and whether billing decisions withstand review. The article helps readers understand the compliance risk created by shifting CMS guidance and the importance of maintaining clear records.

Article Sections

1. Consult documentation and record support

   Explains the need for documentation of a consult request in the patient record and discusses how providers should approach consult-related documentation in general.

2. Verbal requests and chart notation

   Addresses situations where a consult request is made verbally and describes the broader recordkeeping approach discussed in the article.

3. Postoperative care and related billing distinctions

   Covers how the article frames consults in relation to postoperative management and other forms of care coordination.

4. CMS guidance changes and professional oversight

   Discusses the withdrawal of CMS guidance and the article’s description of the policy and oversight context involving CMS and the AMA.