Consultation vs follow-up billing in Alberta

Getting the consultation/follow-up distinction wrong is one of the most common billing errors in Alberta — and it cuts both ways.

Bill a follow-up when the encounter qualifies as a consultation, and you're leaving money on the table. Bill a consultation without meeting the documentation requirements, and you're creating audit exposure. This page covers the key differences Alberta physicians need to know.

What makes a consultation different from a follow-up?

In Alberta SOMB billing, a consultation requires three specific elements that a follow-up visit does not:

1. A referral from another physician — the encounter must be initiated by a referring physician's request for specialist opinion
2. A comprehensive assessment — the consultant must perform and document a thorough evaluation relevant to the referral question
3. A report back to the referring physician — the consultant must communicate findings and recommendations to the referral source

If any of these three elements is missing from your documentation, the encounter does not qualify as a consultation under SOMB rules — regardless of the clinical complexity.

Key differences at a glance

Common errors physicians make

Underbilling: coding a consultation as a follow-up

This happens when a physician sees a new referral but defaults to the follow-up code out of habit or uncertainty. The referral was made, the assessment was comprehensive, and the report was sent — but the billing code doesn't reflect the actual service. This is the most common direction of error and results in direct revenue loss.

Overbilling: coding a follow-up as a consultation

This happens when a physician bills the consultation code for a returning patient or for an encounter where one or more of the three consultation requirements isn't met. This creates audit exposure — if the chart doesn't show the referral, the comprehensive assessment, and the report back, the consultation code won't survive scrutiny.

Missing the re-consultation opportunity

A re-consultation may be billable when a patient is referred again for a new or significantly changed clinical problem. Physicians sometimes default to follow-up codes for returning patients even when a new referral has been made for a distinct issue.

Documentation requirements for defensible consultation billing

To bill a consultation code that will withstand an audit, your chart should clearly document:

• The referring physician's name and the referral question
• A comprehensive history and examination relevant to the referral
• Your assessment, diagnosis, and management plan
• That a report was sent (or will be sent) to the referring physician
• For re-consultations: the new or changed clinical problem warranting re-referral