Evaluation and Management: Consultations (Q&A) (September 2014)

September 2014 page 13 Evaluation and Management: Consultations Question: A patient visits the office of an ear, nose, and throat (ENT) specialist and tells the office staff that a general practitioner referred him to a specialist for an ongoing problem with sinusitis. The ENT office has not received an oral or written request from the general practitioner's office. Can this patient visit be reported as a consultation (99241-99245) based upon the patient's statement? Answer: No. If the presumed referring physician does not communicate a formal request for a consultation, either in verbal or written form, this is not a...

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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 reviews consultation reporting in evaluation and management, focusing on who must request the service, what documentation is expected, and how to think about encounters that begin with a patient statement rather than a formal request from another source. It is intended for coders, billers, and clinical documentation staff who need a general understanding of consultation-related E/M guidance.

Why This Topic Matters

Consultation reporting depends on whether the encounter meets the basic service requirements and documentation expectations. Understanding these distinctions helps reduce coding errors for specialist visits and other referral-based encounters.

Article Sections

  1. September 2014 page 13

    Introductory publication information and placement within the source issue.

  2. Evaluation and Management: Consultations

    General discussion of consultation reporting in evaluation and management services, including request and documentation concepts and the distinction between consultation-type encounters and other visit types.

What You Will Learn

  • The general concept of an E/M consultation
  • What documentation is associated with consultation encounters
  • How consultation reporting differs from other visit categories
  • Which kinds of requesting sources are discussed in the article

Who Should Read This

  • Medical coders
  • Billing staff
  • Clinical documentation staff
  • Physician office staff
  • Specialty practice administrators

Codes Discussed

Code Ranges Discussed


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