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consultation requirements HELP!

  1. #1
    Default consultation requirements HELP!
    Medical Coding Books
    what documentation is required on the Consultation sent to the physican who has requested for my physicians opinion.

    Would the physican need to send hpi, exam, etc. Or could he send his findings and opinion.

    Thanks in advance.

  2. #2
    Duluth, Minnesota
    isn't that one in the same? Doesn't his report have all the elements? does he do two different reports? wouldn't his documentation support "who" requested the consult/HPI, his findings/ROS/exam and the fact that the copy of "his" report is being sent to the primary doctor, stating "his" findings and opinion?????
    Last edited by dmaec; 11-25-2008 at 04:34 PM.
    Donna, CPC, CPC-H

  3. #3
    North Carolina
    "After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician."

    Scroll down to 30.6.10

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    Rebecca CPC, CPMA, CEMC

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  4. #4
    It sounds like they are dictating a separate letter to send back to the requesting provider. In that case there are no required elements aside from their recommendations that I am aware of. If there are specific elements required I would like to know about them. Generally, the physicians I work with just send a copy of their note for that day. The few that do a letter tend to list almost everything from the note with a brief overview of the exam elements.

    Laura, CPC

  5. #5
    I would like to thank you all for your imput it was very helpful and appreciated.


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