Evaluation and Management FAQs


  1. Does CMS permit payment for consultative E/M services?

    CMS permits payment for medically necessary consultative E/M services. The specific E/M codes previously used to represent consultative services were discontinued in CY 2010, but the services remain valid for Medicare billing and are represented by E/M codes currently in place to represent both inpatient and outpatient E/M services.
  2. What requirements apply to documentation for consultative services?

    The attending physician/NPP who is requesting the consultation must enter a consultation request in the medical record. This request may state a specific consultant’s name (e.g., “Dr. Smith”) or may state a request based on the consulting specialty (e.g., “Neurology”). Upon completion, the consultant must enter a report of his/her findings in the medical record and may also enter orders for additional diagnostic testing.
  3. Can a consultative service be performed on a split/shared basis?

    As of 1/1/2022, CMS has confirmed that consultative services may be performed on a split/shared basis.
  4. How does modifier AI apply to consultative services?

    Modifier AI is an informational modifier used to identify initial inpatient E/M services by the attending physician. The modifier is not applicable to claims for subsequent hospital care by the attending physician. Consulting physicians do not use modifier AI for either initial or subsequent inpatient claims.
  5. Please define correct coding for an ER service by a consulting provider, when requested by an ER provider.

    Answer: CMS IOM Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.11(A) indicates that “Any physician seeing a patient registered in the emergency department may use emergency department visit codes (for services matching the code description). It is not required that the physician be assigned to the emergency department.” Further, 30.6.11(F) indicates “If the emergency department physician requests that another physician evaluate a given patient, the other physician should bill an emergency department visit code.”
  6. How are consultation services billed for patients who are receiving observation care?

    Consultation services for patients who are receiving observation care are billed with outpatient codes 99202-99215, as per CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12, Section 30.6.8.

    “For example, if an internist orders observation services and asks another physician to additionally evaluate the patient, only the internist may bill the initial and subsequent observation care codes. The other physician who evaluates the patient must bill the new or established office or other outpatient visit codes as appropriate.”

Revised 7/14/2023