Pulmonology Coding Alert

Answer: Consultations are among the most frequently miscoded evaluation and management (E/M) services. According to Medicare guidelines, a consultation will be paid if the following criteria are met:

The physician provides an opinion or advice regarding evaluation and/or management of a specific problem, after another physician requests it.

A request for a consultation from an appropriate source and the need for consultation are documented in the patients medical record.

After the consultation is provided, the consultant prepares a written report of his/her findings and provides it to the referring physician.

A physician/consultant can initiate diagnostic and/or therapeutic services at an initial or subsequent visit. Subsequent visits (not performed to complete the initial consultation) to manage a portion or all of the patients condition should be reported as subsequent care.

If consultation criteria are met, a physician should bill his or her first encounter with the patient as a consult. There are times, however, when a physician cannot diagnose a patient at the first visit.

The physician may order diagnostic tests to assist in forming a diagnosis. Those tests may take a day or two to be completed. In this situation, the first visit is billed as a consult and additional visits are billed as follow-up consultations until a diagnosis is established.