Evaluation and Management: Consultations (Bonus Q&A) (December 2015)

December 2015 page 18a Evaluation and Management: Consultations Question: If a patient with a specific condition or problem is referred to a surgeon, is the surgeon able to report a consultation code? Answer: Often the terms consultation and referral are mistakenly interchanged, but these terms are differentiated in the CPT code set. Careful documentation of the services requested and provided will alleviate much of the confusion in reporting consultative services. As defined in the CPT® 2016 codebook (p 19), "… consultation is a type of evaluation and management service provided at the request of another physician or appropriate source...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article addresses a consultation-versus-referral question within evaluation and management coding. It is aimed at coders, billers, and clinicians who need a general understanding of consultative service documentation and communication requirements discussed in a CPT Assistant Q&A format.

Why This Topic Matters

Consultation reporting can be misunderstood when a patient is sent to another physician for specialized care. This Q&A helps readers recognize the documentation and communication themes that affect whether a service is treated as a consultation in CPT-based reporting.

Article Sections

  1. December 2015 page 18a

    Introduces the Q&A format and the consultation topic within evaluation and management coding.

What You Will Learn

  • How consultation services are framed within evaluation and management coding
  • What general documentation themes are associated with consultative services
  • How the article distinguishes consultation from referral at a high level
  • What types of communication with the requesting source are discussed

Who Should Read This

  • Medical coders
  • Coding auditors
  • Billing staff
  • Physicians
  • Practice managers

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