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Consult This List Before Coding E/M

Published on Wed Jun 22, 2005

We've straightened out the fine line between consultation and referral The next time you have to decide between a consultation and referral, just look to this handy template that reveals the key factors for choosing the right evaluation and management code for your situation.

Consultation 

Suspected problem
Undetermined course of treatment
Only opinion/advise sought
Patient follow-up with attending doctor
Final diagnosis unknown
Recommended documentation:
Please examine patient and provide me with your opinion of his/her condition

Referral

Known problem
Prescribled/known course of treatment
Transfer care for that problem
Patient advised to return for appointment
Final diagnosis typically known at time of referral
Recommended documentation:
Patient is referred to you for evaluation and treatment of his/her condition

Courtesy of Annette Grady, CPC, CPC-H, healthcare consultant for Eide Bailly in Bismarck, N.D., and AAPC National Advisory Board member.
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