When coding for a consults, would the first visit with Gastroenterology be considered a consultation or would an E/M be used? I read that "the consulting physician’s advice as a guide, the attending/requesting physician intends to continue to treat the patient. If the requesting physician intends for the consulting physician to assume immediate care of the patient’s condition, the service is not a consultation, but instead a referral or transfer of care." So when or how does one determine if the visit was a transfer of care/referral or when a physician assumes immediate responsibility for a patient’s care? Does the provider doing that visit need to state they're taking the care over?
Scenario: Patient was referred to the GI clinic by PCP (APRN) for acute pancreatitis without necrosis. CT did not demonstrate pancreatitis. Lipase only slightly elevated at 83. Acute pancreatitis is unlikely the cause of her RUQ pain, and given her history of the RUQ pain and reports of occassional dyspepsia I will order an EGD to rule out PUD, gastritis, GERD. Biopsies for H. pylroi appreciated. Will also recheck Lipase to ensure it has returned to normal and Celiac serology. Will start the patient on a PPI.
The way I interpret the above scenario is that the PCP has transferred the care to another physician to take over the responsibility for managing the patient’s complete care for the condition. The 3 elements (request, reason and report) were met but the intention(s) of the visit isn't very clear.
Any information provided would be helpful and thank you in advance
Scenario: Patient was referred to the GI clinic by PCP (APRN) for acute pancreatitis without necrosis. CT did not demonstrate pancreatitis. Lipase only slightly elevated at 83. Acute pancreatitis is unlikely the cause of her RUQ pain, and given her history of the RUQ pain and reports of occassional dyspepsia I will order an EGD to rule out PUD, gastritis, GERD. Biopsies for H. pylroi appreciated. Will also recheck Lipase to ensure it has returned to normal and Celiac serology. Will start the patient on a PPI.
The way I interpret the above scenario is that the PCP has transferred the care to another physician to take over the responsibility for managing the patient’s complete care for the condition. The 3 elements (request, reason and report) were met but the intention(s) of the visit isn't very clear.
Any information provided would be helpful and thank you in advance