Wiki Consult question

cleanclaims

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I would like other opinions on whether or not you would audit this and decide that it meets criteria for a consult (vs. new patient code):

CONSULTING PHYSICIAN
John Black, M.D.

REASON FOR CONSULTATION
CHRONIC KIDNEY DISEASE

HPI

Mrs. Doe is a pleasant XX year old female being see today for initial evlauation of chronic kidney disease. Labs available to me from her primary care physician show a baseline creatinine XXX.............

Assessment and plan:

List out diagnoses and plans for them

I recommended to Mrs. Doe that she does not use RX on a regular basis.......

No consult letter is sent but information is sent to physician listed under consulting physician above.

What say you?
 
I see no consult here. There is no real clear cut reason as to why the consult was requested. What was the requesting doctor asking for? so I say no consult.
 
I don't see a consult either

This looks like the pcp sent her to a nephrologist for her CKD. He states "initial evaluation" to me this indicates he plans on seeing her for this problem from now on.

Which I know you can do a consult and then pick up the care for that problem but if the intent is to take over care all along there is no consult.

Laura, CPC, CPMA, CEMC
 
Where's the exam?

Plus .. where's the exam? You need three of three (unless time is used and more than 50% of total time was spent in counseling/coordination of care).

F Tessa Bartels, CPC, CEMC
 
I agree with no consult, no clear indication of what the consultation was for and no clear indications of findings for the PCP
 
Consult

I agree, this is not a consult as he states she is here for her initial evaluation which indicates to me a transfer of care.
 
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