heatheralayna
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I am having a challenge with some of my physicians. Somewhere along the way one of them has been told (not by me) that if they do a level 3 or less they don't have to dictate inpatient consultations. ??!!
When they provide inpatient consultations they are documenting in the hospital records. Often the referring physician is a hospitalist and they claim they don't have an office to send anything to so why do they have to dictate? The hospital chart is their chart. I am not familiar with exactly how hospitalists prefer documentation, if they have other charts, etc. I do have access to the scanned hospital record.
per CPT guidelines the consult "...must also be documented in the patient's medical record and communicated by written report to the requesting physician... " I have always interpreted that to be dictated. My physician is saying it doesn't SAY dictated; therefore, why can't written suffice?
Does anyone have any recommendations on where I can find any written guidelines that refer to dictation? Has anyone come across this situation or have any guidelines in their office?
Please let me know.
When they provide inpatient consultations they are documenting in the hospital records. Often the referring physician is a hospitalist and they claim they don't have an office to send anything to so why do they have to dictate? The hospital chart is their chart. I am not familiar with exactly how hospitalists prefer documentation, if they have other charts, etc. I do have access to the scanned hospital record.
per CPT guidelines the consult "...must also be documented in the patient's medical record and communicated by written report to the requesting physician... " I have always interpreted that to be dictated. My physician is saying it doesn't SAY dictated; therefore, why can't written suffice?
Does anyone have any recommendations on where I can find any written guidelines that refer to dictation? Has anyone come across this situation or have any guidelines in their office?
Please let me know.