Reader Question: Documentation Distinguishes Consult

Article Overview

This reader Q&A focuses on documentation distinctions between consultation and referral scenarios in physician practice, with emphasis on how requests, responses, and transfer-of-care context are documented. It is intended for coders, billers, and clinical staff who need to understand when an encounter is being treated as a consult versus a standard office or inpatient/outpatient visit. The article discusses the general documentation elements expected for consultation-style encounters and contrasts them with referral situations, using a brief surgical specialty example to illustrate the difference.