Internal Consultations

Lisa A

Columbus, GA
Best answers
I am looking for feedback on documentation for internal consultations.

We are an ophthalmology practice and have consulation request from one physician to another that happen internally.

Since it is a shared medical record does there have to be a written report back the the requesting physician? Would it be appropriate to add a comment on the internal consultation request form that reads "Please refer to the consultant's report in the medical record documentation."?

I think the above is acceptable documentation but would like to know what others think.

Unless the physicians are two different specialities, then I don't see how you can bill for a consult. It would just be an established patient ov for the second physician.
Do you have a way to "in-basket" lab results, etc to the physician attention? If so, I would send the consult notes that way as well as documenting that it was sent in the EMR.
It is uncommon, but certainly possible that two physicians of the same specialty, within the same practice may refer a patient internally to one another for what CPT defines as "Consultation" services.

For instance, if one provider specializes in a particular service within his/her specialty, it might be necessary to request a consultation from his/her partners for a condition, problem or opinion that he/she feels it outside his/her professional expertise.

Again, this wouldn't usually be a frequent occurance. Have documentation that clearly substantiates the necessity of this internal referral and be prepared to produce that to the payers.

Hope this helps.