Wiki Need some advice!

[GSCoder07]

I need someone else's thoughts on this one....
The patient was admitted to the hopsital. Dr. A was consulted to see him. Dr. A only has an extremely brief note dated 09/05/13 basically stating the patient's principal problem and the surgery that will be performed by him, nothing else. Not an HPI, ROS, PFSH, nothing. Dr. A has a consultation note dictated on 10/18/13 that states this is when the consultation took place. He did not bill a consultation on 09/05/13 but is trying to bill one for 10/18/13.
My question is this, can he bill for a consult if he did not bill one out in September? Would this be considered to be an established patient (which is what I'm thinking)?
If any of this sounds confusing, I do apologize.
Any help would be greatly appreciated!

 

[mlbaker1974]

I need someone else's thoughts on this one....
The patient was admitted to the hopsital. Dr. A was consulted to see him. Dr. M only has an extremely brief note dated 09/05/13 basically stating the patient's principal problem and the surgery that will be performed by him, nothing else. Not an HPI, ROS, PFSH, nothing. Dr. A has a consultation note dictated on 10/18/13 that states this is when the consultation took place. He did not bill a consultation on 09/05/13 but is trying to bill one for 10/18/13.
My question is this, can he bill for a consult if he did not bill one out in September? Would this be considered to be an established patient (which is what I'm thinking)?
If any of this sounds confusing, I do apologize.
Any help would be greatly appreciated!

When coding consultation codes. new or established patient doesn't matter the codes are the same, what does matter is the content of the documentation (ie, request for consultation, documentation of the encounter, and report to referring physician). And yes he may bill for the consult if the documentation supports it.