Wiki Office Consult Question

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renifejn

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I have an office consult where the first line of the hx states "Pt is a 20 y/o male who comes in for the evaluation of abnormal screening echocardiogram" Nothing states who requested the consult. Then just goes into some add'l info.


....but....

the letter to the referring physician (which is esentially the office visit documentation copied) is attached and "I had the pleasure of seeing your pt, xxxxx xxxx, in consultation at your request. As you know, xxx xxx comes in for evaluation of an abnormal screening echo.

Would you could use the letter documentation for the "Request" portion of the 3 r's to bill this as a consult or would you bill as a new patient?
 
Yes that is sufficient as long as you've met the consult requirements. As long as an audit trail is established back to the referring MD. A letter/report back with the referring MD, establishes that. and as you stated, the letter is the office visit copied (which should hold the 3/3 key components), so you're fine.
 
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The use of the words "evaluation" and "referring" can point to a transfer of care. However, your provider does make reference to seeing the patient for "consultation at your request". If I audited this service, I would be more comfortable if I had a written request from the "requesting" physician. You can easily ask the requesting provider for this. I hope this helps.
 
Yes, you have a consult

Yes, you may use all the documentation available for a specific date of service, and you can use the letter to the requesting physician for proof that it is a consult. However, it never hurts to educate your physician about documentation.

We ask our physicians to list the chief complaint as: consultation for xxx (reason). And to separately list the requesting physician. (Notice we don't use the word "referring.").

Most of our physicians document their office consultations as a dictated letter to the requesting physician. Inpatient consultations in our hospital's dictation/transcription system have a pre-determined template of headings that includes: REQUESTING PHYSICIAN:. These headings can't be deleted, so if the dictator doesn't state the info there will be an obvious blank when s/he goes to sign the note, prompting him/her to complete that information.

F Tessa Bartels, CPC, CPC-E/M
 
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