Wiki consultations - again

[tristate]

My dear fellow E&M coders...
Being new to this forum, I feel bad for asking so many questions, but I do appreciate all of you for your assistance. I have been researching and reading all of the E&M information I can find. I think I have a really good understanding of the exam and MDM part. Still having some problems with HPI. Enough of my babbling..... My question now is........
All of the consults I code are for patients who are here for a cardiac consult prior to orthopedic surgery. As far as chief complaint - shouldn't he be documenting the patient's cardiac reasons for the consult instead of something like "Right knee pain with ambulation for the last 3 years. Patient uses a walker. The fact that the patient has an orthopedic problem is not why the cardiologist is seeing her. Am I on the right track? He does document the patient's cardiac problems under past medical history.
Thank you
Debby

 

[bigredcag]

i had this same problem, the dr needs to state the reason for the visit for that date of service. (ie pt is here for cardio consult form Dr. A) the ortho stuff is more past history.
the reason they may be stating it this was is it seems like a preop consult which alot of insurance have a problem paying the V code.
good luck

 

[FTessaBartels]

Physician training

I've trained my phsyciains that the chief complaint for a consult is always:
"Asked to see patient by Dr Requestor in consultation for X problem."

This way it is clear that this is a consultation and what the reason for the consult is.

Absent such clear documentation, we code a new or established patient visit.

If they want to be paid for a consult, it's not too much to ask that they clearly identify the service as a consult.

F Tessa Bartels, CPC, CEMC