Wiki Consultation Letters

[medicalsec]

Our doctors are often so busy that they do not dictate their consultation report until after the surgery. They actually explain their complete course of treatment. I think that this would substantiate a transfer of care rather than a consultation because they are not giving their opinion prior to performing surgery. Am I correct?

Thanks,

DEE

 

[FTessaBartels]

Why is patient sent to you?

If the patient is being sent to you to have surgery ... then it's not a consult.

If the surgeon is seing a patient in consultation, and decides that surgery is needed ... even if surgery occurs the same day ... then it's a consult. The surgeon's dictation on the consultation should be specific to the decision for surgery and not cover what happened during or after the procedure.

I know they are busy. I know it's a headache to dictate two notes. But if they want to be correctly paid for the services they render, that's how they need to document.

F Tessa Bartels, CPC, CEMC