IP consult

cchilva

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One of my Dr's did a consult IP. Here is the report

Reason for Consult: Redness on the right thigh

History of Present Illness: This 66 year old Caucasion male was seen for evaluation of an extremely tender, erythematous and painful plaque-like eruption by history located on the dorsum of his right thigh. This was a couple of days ago and, when seen today, most of this condition has spontaneously resolved. He relates the erythema is virtually back to normal. The swelling and tenderness have dissipated and the pain is negligible. His feeling was that this may have been triggered by compression, laying on it, that kind of a physical constriction and, at this point, I have no way to help decide the etiology either way.

What we have decided is to hold off anything and just see if Mother Nature will continue to provide a spontaneous resolution to this problem.

Past Medical History: We have reviewed his past history and it is significant for some surgeries on the hemorrhoidectomy, polypectomy. He is currently evaluated for some abdominal problems including urinary retention.

So I feel that perhaps just careful monitoring seems to be the most prudent responds and so, if there is a resurgence of his condition and a recurrence of it, I would be most happy to return and re-evaluate and see what the appropriate response should be.

Thank you very much for allowing me to consult and participate in the care of this patient.

Does anyone see a consult in this report? I am working on learning how to code E/M and would appreciate any input on this.
 

LLovett

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Did a copy go to the requesting provider and was the requesting provider mentioned somewhere, or is what you have posted it?

If the requirements are met, I see the reason and recommendations just need the report and the requesting provider, then I would put this thru as a 99251.

The only element of exam I am pulling out of this is inspection of the skin.

Laura, CPC
 
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Inpatient doesn't need separate report

Inpatient consults do not need a separate report, as there is an assumption of a shared medical record.

The requesting provider should be listed; however, you may have a record of an order for a consult in the chart, which might suffice.

It seems clear that your physician was asked to see this patient about this particular problem. S/He's done a problem focused exam and history, and has straightforward MDM (self-limited or minor problem). His/her record in the chart serves as the report back to the requesting physician. S/he is clearly not taking over management of this issue, but gives recommendations (wait-and-see is a recommendation). This meets the requirement for 99251 (assuming the requesting physician issue is resolved).

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

LLovett

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That is interesting about not needing a report back. I can see that when it is handwritten and in the physical chart but many of the specialists I deal with dictate and send a copy of the dictation to be put in the chart.

Laura, CPC
 
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