Documenting consults/new patient visits in a letter format

Messages
3
Best answers
0
We have told our physicians that we are unable to code a visit when it is in a letter format with salutation, etc. back to the referring physician. Is there any guidance on this procedure?
Bruce Brunson, MD, Physician Advisor
 
Messages
811
Best answers
0
The 3 R's for consultations includes a component for "Report"; this is a separate document in which the consulting provider responds to the requesting provider with regards to the findings and recommendations. The report should not be included within the encounter note. However, the encounter note needs to mention that a letter was drafted and sent to the requesting provider.

From https://www.aapc.com/blog/24816-consult-or-not/ -
“After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician,” CMS guidelines require.

The report is not a thank you note to the requesting physician for referring the patient, nor is it a courtesy copy of the history and physical. Rather, the report provides instruction to allow the requesting physician to continue treating the patient.

In most outpatient settings, the consulting physician’s report (like the consult request and reason) is a separate document sent from one physician to another. In the emergency department (ED) or other outpatient setting in which the medical record is shared between the requesting and consulting physicians (such as a large, multi-specialty group practice), the request, reason, and report may be a part of the shared record. Likewise, in an inpatient setting, the request, reason, and report may be part of the shared medical record, says the manual."


Also, try looking here:
https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf
http://compliance.uclahealth.org/workfiles/PDFs/New_Patient_Vs_Consultation.pdf
https://www.aapc.com/blog/25499-remember-the-three-rs-for-payers-accepting-consults/

Hope that helps!
 
Top