Wiki Consult question

Wilmington, NC
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When our physician sees a patient in the office, and then the patient is admited a couple of days later by another physician group, and this admitting group requests that our physician see their patient in consult at the hospital, is it allowable for our physician to use his office note (less than 30 days old), as his consult note, if he updates it and places it in the patient's hospital record. I know it's okay to do this with H&P's, but is it okay to do this with consults?

Our local hospital says it meets their requirements, but is okay per Medicare?

I appreciate your assistance with this :)

Okay with whom?

It's probably sufficient to use the office visit note to communicate medical information to the specialist requesting the "consultation" ... after all, when that physician wants is information on existing conditions/co-morbidities and how to manage them while patient is hospitalized. This, of course, depends on how recently the office visit occurred and whether your physician is certain there is no new information that would affect his recommendations on the medical mangement of the patient.

However, you CANNOT bill for an inpatient consultation (or any other service) when all you have done is place a copy of a previous visit's documentation in the patient's chart.

You must have a face-to-face encounter with a patient to code an E/M service for that date.

Hope that helps.

F Tessa Bartels, CPC, CEMC
Last edited:
OK for what purpose?

Are you asking if it is OK from a documentation standpoint, or a coding and billing one? I would guess the provider billed for the office consult. Are you asking if that same documentation can be used to support the coding & billing of the hospital consultation?
consult question continued...

Yes, I'm wondering if an office note, less than 30 days old, updated and placed in the patient's chart at the hospital would be sufficient to BILL for a consult. I know the hospital (as far as their requirements are concerned is fine with an updated office note for their medical records) What I need to know is it enough - or considered appropriate documentation to BILL for a consult. I'm sure our physician saw the patient face-to-face, but was too lazy to complete another consult note when he knew there was a perfectly good one in our EHR he could use. But is that sufficient documentation to bill Medicare?

Of course - knowing Medicare no longer use consult codes ....

The answer is NO

No, you cannot bill for THIS visit based on documentation from a previous visit (except, of course, you may reference the ROS and PFSH from a previous encounter).

Hope that helps.

F Tessa Bartels, CPC, CEMC