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Wiki Hospitalist consult

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Question:
A hospitalist is asked to do a consultation (99254 was billed) for "probable congestive heart failure. In his chart note it clearly states the reason and request for the consult. My issue is that it appears that her report to the requesting physician is her assessment and plan at the bottom of the chart note along with "thank you for the consultation". I know that in an office setting this is pretty starightforward regarding the report back to the requesting provider. My question is in a hospital setting when the requesting physician is the same chart. I was hoping for some backup and guidance before I disucss this the physician regarding their consults.
 
Shared medical record

An inpatient consult does not require a separate report being sent to the requesting physician, as there is a presumtion that the physicians treating the inpatient all have access to the shared inpatient medical record.

So if the documentation meets the standards for a consultation on an inpatient, no additional separate report needs to be sent to the requesting physician.

F Tessa Bartels, CPC, CEMC
 
Yes, Tessa is correct. As long as the record is shared, no seperate report is required. If audited, you'll need to prove the referring physician has access to the consultant's record.
 
I was hoping this would be the consensus as I wasn't quite sure how to break this to the physicians. :) Thank you
 
No, there is no issue. I was preparing for my class with them tomorrow and I just had the question as I was touching on consults getting my ducks in a row.
 
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