We have an issue that I was hoping to get some clarification on. Our office has an EMR system which has physician progress notes as well as a place in which the physicians can place referral requests. These requests can include testing as well as evaluate and treat. According to our policy, if a physician puts in a referral for 'evaluate and treat', this is considered a consult. If a physician puts in a referral for 'test', this is not considered a consult, of course.
The question I have is if a physician has documented in his/her progress notes that they are referring for a test but in the referral it's noted 'evaluate and treat' (which, again, is considered a consult in our system) which do I go by; the referral or the physician's notes.
A physician and fellow coder states it's ok to go by what is in the referral itself. One reason was if we were an outside office who didn't have access to the physician's notes, we wouldn't see what they had in their actual notes - only the referral. This physician also contacted some of the physicians who stated if they put in a referral for 'evaluate and treat' then they are asking for this physicians' opinion not only testing, no matter what is in their progress notes.
So I'm left with the question of is this a consult or not???
The question I have is if a physician has documented in his/her progress notes that they are referring for a test but in the referral it's noted 'evaluate and treat' (which, again, is considered a consult in our system) which do I go by; the referral or the physician's notes.
A physician and fellow coder states it's ok to go by what is in the referral itself. One reason was if we were an outside office who didn't have access to the physician's notes, we wouldn't see what they had in their actual notes - only the referral. This physician also contacted some of the physicians who stated if they put in a referral for 'evaluate and treat' then they are asking for this physicians' opinion not only testing, no matter what is in their progress notes.
So I'm left with the question of is this a consult or not???