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Re: Consultation Letters

  1. Default Re: Consultation Letters
    Medical Coding Books
    I was wondering if many offices send the chart notes to the doctor that is requesting the consultation to meet the consultation requirement. Our charts seem to be constantly on the move, and often by the time the doctor gets to the chart it is after the procedure, which to my mind would confirm a transfer of care. Our doctors give our charts to the surgery scheduler to discuss the scheduling while the patient is in the office, so the chart often gets dispersed to multiple employees before it returns to the doctor. Do must offices dictate a formal letter? Any suggestions as to how to simplify the process.

    Thanks,

    Dee

  2. #2
    Default
    Quote Originally Posted by medicalsec View Post
    I was wondering if many offices send the chart notes to the doctor that is requesting the consultation to meet the consultation requirement. Our charts seem to be constantly on the move, and often by the time the doctor gets to the chart it is after the procedure, which to my mind would confirm a transfer of care. Our doctors give our charts to the surgery scheduler to discuss the scheduling while the patient is in the office, so the chart often gets dispersed to multiple employees before it returns to the doctor. Do must offices dictate a formal letter? Any suggestions as to how to simplify the process.

    Thanks,

    Dee

    Dee,

    I've seen it done both ways, at one practice I worked for they would dictate their note and CC the requesting physician a copy of the chart note the chart note would start off with something like "thank you for consulting me on your patient Mrs. X. Other times they would dictate a separate letter and keep the "progress note" in the chart.
    Roxanne Thames CPC, CPC-I, CEMC
    rthamescpci@gmail.com


    "Remember the greatest gift is not found in the store but in the heart of true friends"

  3. #3
    Location
    Milwaukee WI
    Posts
    4,466
    Default We dictate a letter
    Our surgeons dictate a letter to the requesting MD immediately after the visit (or at the end of the clinic day). Our official patient medical records are electronic, but the scheduling staff does make a "shadow" chart they work from for pre-auths, etc.

    It has a copy of the basic demographic info and insurance info to start. The admin assistant will schedule the surgery, request a critical care bed (if deemed necessary post op), and get to work on the pre-auths using the shadow chart. If an insurance company needs clinical info, the AA can easily print that from the electronic record and send it off.

    It sounds from your post that it would be a good idea to look at the processes in your office. Do your schedulers, etc need the entire medical chart to do their jobs? It's a good idea for your surgeon to be dictating the consult report within 24 hours of that first visit. But even if s/he doesn't get to it until much later, that first visit may still be a consultation.

    Remember ... if the PCP is sending the patient to you to have surgery, it's NOT a consult. If the PCP is sending the patient to you for advice on management of a problem, it's a consult, even if the "advice" of your surgeon is to operate immediately.

    F Tessa Bartels, CPC, CEMC

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