Reader Question: Document E/M Components for Consultation

Article Overview

This reader question addresses documentation and reporting considerations for a surgeon called into an operation to evaluate a possible injury. It explains the general distinction between consultation-style documentation and other E/M documentation patterns, notes the effect of payer rules on whether consultation reporting is allowed, and discusses what to do when the record lacks enough information for E/M billing. The article is useful for coders, surgeons, and billing staff who handle intraoperative consult scenarios and documentation review.