Consultations: Answers to Perplexing Questions (August 2001)

Why This Topic Matters

Consultation coding is a common source of claim errors because the service depends on documentation and context, not just the label used in the referral process. Clear understanding of this guidance helps support more accurate E/M reporting and reduce confusion between consultation codes and other visit codes.

Article Sections

1. August 2001 pages 1-4

   Introductory background on the consultative process and how modern practice affects evaluation and management coding. The section frames the article’s focus on when consultation reporting is appropriate.

2. How can I determine when to code an evaluation and management (E/M) service as a consultation?

   General criteria for identifying a consultation service and documenting the request, opinion, and communication. The discussion also contrasts consultation reporting with other office and hospital E/M options.

3. Is it appropriate to code a consultation when the diagnosis is already known by the requesting physician and/or by the consulting physician?

   Guidance on consultation reporting when the clinical problem is already established and the request is made for additional opinion or advice. This section includes a summary of the core consultation requirements and the role of the requesting source.

4. Clinical Examples

   Illustrative scenarios showing how the general consultation guidance applies in different clinical settings. The examples address office, emergency department, and procedure-related encounters.

5. When the physician initiates diagnostic or therapeutic services at the time of the "consultative" service, is the encounter still considered a consultation?

   Discussion of consultation encounters in which diagnostic or therapeutic services are started during the same visit. The section focuses on the relationship between initiating services and the consultative event.

6. In the context of question three, when does the consultative service end?

   A short explanation of when the consultative portion of care is considered complete. The section centers on communication back to the requesting source.

7. When the physician assumes the responsibility for care at the time of the consultation E/M service, should the service still be coded as a consultation?

   Guidance on consultative services when the consultant also becomes responsible for ongoing care. The section references how subsequent services are generally handled in office and hospital settings.

8. Does initiation of a diagnostic service constitute assumption of management and terminate the consultation?

   Clarification about diagnostic services begun during a consultation and their relationship to management assumption. The section addresses how diagnostic work fits within the consultative encounter.