Wiki consult question

[codegirl0422]

I was wanting to see if someone can help me.

I have always been told that if the word referred, referring physician shows up in a consultation report that it is no longer a consultation. I have a doctor that truly did a consult, her opinion/advice was being requested and the 3 R's were met. However, she starts her dictation "Referring physician Dr-----" then under HPI she states the patient is seen in consultation for Dr----- then the reason for the visit. I think she needs to take out the word referring but I am being told it clearly states consultation in the body of the report. And they don't see a problem with it.

Thanks in advance for any help on this.

 

[FTessaBartels]

Physician education

Physicians (and coders, and insurance carriers, and patients) use "referral" and "request" interchangeably. It's an uphill battle to get them to stop this.

In your case, it sounds as if there is clear indication that a consultation was requested by the verbiage in the body of the report. I'd count it as a consult and not worry about a heading that says "referring physician."

BUT ... I would do my best to try to train the physician to use the title: Consultation requested by: Requesting Physician, MD

This would help head off any questions by an auditor (and any potential for having to refund and rebill, not to mention fines).

Maybe you can get the doctor to think of this kind of attention to the details of documentation as "preventive medicine."

Good luck

F Tessa Bartels, CPC, CEMC