Understanding E/M Categories and Consultation Services for Accurate Coding
- MedicalCodingbyJen
- 5 hours ago
- 4 min read
Accurate coding of Evaluation and Management (E/M) services is essential for healthcare providers to ensure proper reimbursement and compliance. The E/M section is organized into categories based on the site of service, such as office visits, hospital inpatient care, consultations, and others. Understanding how these categories and their subcategories work helps medical coders and providers select the correct codes and avoid common errors.
This post explains the structure of E/M categories, the specific requirements for consultation services, and practical tips for accurate coding. Whether you are a coder, biller, or healthcare provider, this guide will clarify key concepts and improve your coding accuracy. Learn how E/M categories are organized, how consultation services work, and tips to code E/M services accurately for compliance and reimbursement.
E/M Coding Categories Explained: Consultations, Levels & Tips
How E/M Categories Are Organized
E/M services are grouped by the site where care is provided. Each broad category is further divided into subcategories, which then break down into specific levels of service represented by CPT codes. E/M Coding Categories Explained: Consultations, Levels & Tips
Main Categories by Site of Service
Office or Other Outpatient Services
Includes visits to physician offices, outpatient clinics, and home or residence visits.
Hospital Inpatient or Observation Services
Covers care provided to admitted patients or those under observation status.
Consultations
Services provided at the request of another physician or qualified healthcare professional (QHP) to evaluate and recommend care.
Other Categories
Includes emergency department (ED), nursing facility, domiciliary care, and others.
Subcategories and Levels
Each category often divides into subcategories based on patient status or visit type. For example, office visits split into:
New Patient Visits
CPT codes 99202–99205 E/M Coding Categories Explained: Consultations, Levels & Tips
Established Patient Visits
CPT codes 99212–99215 E/M Coding Categories Explained: Consultations, Levels & Tips
Each level corresponds to the complexity of the visit, documented history, examination, and medical decision-making. Learn how E/M categories are organized, how consultation services work, and tips to code E/M services accurately for compliance and reimbursement.
What Defines a Consultation Service
A consultation is a specific type of E/M service provided when one physician or QHP requests another to evaluate a patient and offer recommendations. The consultant may start diagnostic or therapeutic services during the same or later encounters.
Key Elements for Reporting Consultations
To report consultation codes correctly, three practical elements must be met:
Request
The consultation must be requested by another physician, QHP, or an appropriate source.
Render
The consultant performs an evaluation and develops recommendations.
Report
The consultant communicates their findings and recommendations back to the requester in a written report. E/M Coding Categories Explained: Consultations, Levels & Tips
If any of these elements are missing, the service should not be coded as a consultation.
When It Is Not a Consultation
Services initiated by the patient or family without a provider request do not qualify as consultations.
Follow-up visits in the consultant’s office or outpatient facility are reported using established patient office codes, not consultation codes.
Transfer of care, where the consultant assumes responsibility for ongoing management, is coded using appropriate new or established patient E/M codes.
Learn how E/M categories are organized, how consultation services work, and tips to code E/M services accurately for compliance and reimbursement.
Mandated Consultations and Modifier 32
Some consultations are required by third-party payers or other authorities. In these cases, the consultation code is reported with modifier 32 to indicate the service was mandated. E/M Coding Categories Explained: Consultations, Levels & Tips
This modifier helps payers identify consultations that are not optional and may affect reimbursement policies.
Office or Other Outpatient Consultations (CPT 99242–99245) E/M Coding Categories Explained: Consultations, Levels & Tips
Consultations provided in office or outpatient settings, including home or residence visits, use CPT codes 99242 through 99245. These codes apply when the consultation requirements are met, even if the service occurs in an emergency department.
Important Notes
Follow-up visits after the initial consultation are coded as established patient visits (99212–99215) or home visits (99347–99350).
Transfer of care is not reported with consultation codes but with appropriate new or established patient E/M codes.
Practical Examples of E/M Coding for Consultations
E/M Coding Categories Explained: Consultations, Levels & Tips
Example 1: Office Consultation Requested by Another Physician
A cardiologist requests a pulmonologist to evaluate a patient with unexplained shortness of breath. Initiation of the request started with the patients' health insurance provider. The pulmonologist performs an evaluation, orders diagnostic tests, and sends a written report with recommendations back to the cardiologist.
Use CPT code 99243 (office consultation, moderate complexity)
Include modifier 32 if the consultation is mandated by the payer
Example 2: Patient Initiated Visit Without Request
A patient calls a specialist directly for a second opinion without a referral or request from another provider.
Do not use consultation codes
Report the visit using new or established patient office visit codes (99202–99205 or 99212–99215)
Example 3: Follow-Up After Consultation
The patient returns to the pulmonologist’s office for follow-up care initiated by the pulmonologist.
Use established patient office visit codes (99212–99215)
Do not use consultation codes
Tips for Accurate E/M Coding
Always verify if the consultation was requested by another provider or appropriate source.
Document the request, evaluation, and written report clearly in the medical record.
Use modifier 32 when consultations are mandated.
Distinguish between consultations, follow-up visits, and transfer of care to select the correct codes.
Review payer policies as some insurers may have specific rules regarding consultation codes.
Learn how E/M categories are organized, how consultation services work, and tips to code E/M services accurately for compliance and reimbursement.
Learn how E/M categories are organized, how consultation services work, and tips to code E/M services accurately for compliance and reimbursement.
E/M coding
Evaluation and Management coding
E/M categories
E/M consultation codes
CPT E/M codes
Medical coding E/M
CPC exam E/M
E/M coding guidelines
Medical coding compliance
how E/M categories are organized
what defines a consultation service
CPT consultation requirements
modifier 32 consultation
office outpatient consultation CPT codes
medical coding E/M examples
E/M coding tips for coders
consultation vs transfer of care coding
Medical coding reference showing E/M consultation categories and CPT coding guidelines
E/M Coding Categories Explained: Consultations, Levels & Tips
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Click On Which Answer Is Correct Below!
Dr. X asks Dr. Y to look at a 55-year-old male who is in a nursing facility for decubitus ulceration. Dr. Y is unable to obtain history due to current mental st
0%99304
0%99243
0%99234
0%99253
The provider performed a low MDM. The correct code is 99253.