Wiki Questions re: documentation of Consult-E/M

[AmyLitterell]

I just started auditing an ARNP, CDE. On every note I've read so far it states CONSULTATION at the top. My question is this; since Medicare doesn't allow consult codes anymore & she is coding them as an E/M visit.. is it allowable or not to have the word CONSULTATION at the beginning of the chart note? Or does it even matter?

She doesn't document a seperate CC, it is in the HPI.

Please & Thanks for your help!!

 

[laccoe]

I just started auditing an ARNP, CDE. On every note I've read so far it states CONSULTATION at the top. My question is this; since Medicare doesn't allow consult codes anymore & she is coding them as an E/M visit.. is it allowable or not to have the word CONSULTATION at the beginning of the chart note? Or does it even matter?

She doesn't document a seperate CC, it is in the HPI.

Please & Thanks for your help!!

You are correct that all Medicare claims cannot be billed as Consultation, even if that was done. The provider must indicate level of visit. You are stating that a CC is not documented separately. As long as it is clearly obvious in the context of the reason patient being seen (you indicate you see in HP), even when not clearly stated as CC, you may audit as cc. However, if it is not clear from the notes what the cc is you cannot bill out a visit.

You can find this info in the Medicare Billing Manual online