Coding Topic - Consult Downcoded to a lower E/M level ?

What Documentation Is Required?

In order for an E/M service to be considered a consultation, the following criteria must be met and documented:

• A request for a consultation, along with the reason  for a consultation, must be documented by the consultant in the patient's medical record and included in the patient's medical record of the referring practitioner.
• An opinion is rendered by the consulting practitioner. This opinion, along with any other service provided, is documented in the patient's health record.
• A written report of the consultant's findings and opinion or recommendation is communicated back to the requesting practitioner. This report is known to  include a thank-you letter for the consultation request and state exactly what the consultant's opinion is concerning the patient's medical problem.

CPT Assistant, July 2007 indicates that “there may be circumstances when a consultation is initiated by sources other than a physician, such as a physician assistant, nurse practitioner, doctor of chiropractic, … social worker, lawyer, or insurance company.” This helps to explain who can be considered another provider or healthcare entity. Reporting a consultation would be appropriate if the service was at the request of one of these professionals. -

Documentation is the key to getting paid for the consult done.

 It is a lack of proper documentation that leads to a carrier  determination  to downcode  consultation codes to a lower E/M level of service.

If you documented a consult properly and still received a downcode, appeal it immediately and attach the report made out to the referring physician.  Point out to the carrier the referring physician requesting the consultation, the report on record and the rendered opinion given from the physician performing the consultation.

Don't settle for the downcode amount when a consultation has been performed.Appeals that show full proof of the consultation performed will be reconsidered by the insurance carrier for the full payment due.



Julie Pisacane, CCA, CEMC

Member of AHIMA and AAPC