Evaluation and Management Coding Consultation Request Form
Use this form to request a coding consultation for an Evaluation and Management encounter and provide the details needed to review the case.
Requester and Practice Information
Requester Full Name
*
First Name
Middle Name
Last Name
Role / Title
*
Organization / Practice Name
*
Department
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Specialty / Clinical Area
*
Encounter and Coding Context
Patient Encounter Type
*
New Patient
Established Patient
Inpatient
Outpatient
Telehealth
Other
Date of Service
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Place of Service
*
Please Select
Office
Hospital
Emergency Department
Skilled Nursing Facility
Home
Telehealth
Other
Payer Type
Please Select
Medicare
Medicaid
Commercial Insurance
Self-Pay
Workers' Compensation
Other
Main Coding Issue or Question
*
Documentation and Complexity Review
Documentation Completeness/Clarity
*
Incomplete
1
2
3
4
5
6
7
8
9
Excellent
10
1 is Incomplete, 10 is Excellent
Supporting Documentation
*
Attached
Available on Request
Not Available
Other
Visit Elements and Complexity Factors
*
Rows
Documented
Incomplete
Not Applicable
History
1
2
3
Exam
4
5
6
Medical Decision Making
7
8
9
Time Spent
10
11
12
Unusual Circumstances Affecting E/M Selection
13
14
15
Additional Notes / Case Summary
Request Consultation
Should be Empty: