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Internal Consultations

  1. #1
    Default Internal Consultations
    Medical Coding Books
    I am looking for feedback on documentation for internal consultations.

    We are an ophthalmology practice and have consulation request from one physician to another that happen internally.

    Since it is a shared medical record does there have to be a written report back the the requesting physician? Would it be appropriate to add a comment on the internal consultation request form that reads "Please refer to the consultant's report in the medical record documentation."?

    I think the above is acceptable documentation but would like to know what others think.


  2. #2
    St. Louis, Missouri
    Unless the physicians are two different specialities, then I don't see how you can bill for a consult. It would just be an established patient ov for the second physician.

    Melissa Blow, CPC

  3. #3
    Different specialties.

  4. #4
    Do you have a way to "in-basket" lab results, etc to the physician attention? If so, I would send the consult notes that way as well as documenting that it was sent in the EMR.

  5. #5
    Louisville, KY
    It is uncommon, but certainly possible that two physicians of the same specialty, within the same practice may refer a patient internally to one another for what CPT defines as "Consultation" services.

    For instance, if one provider specializes in a particular service within his/her specialty, it might be necessary to request a consultation from his/her partners for a condition, problem or opinion that he/she feels it outside his/her professional expertise.

    Again, this wouldn't usually be a frequent occurance. Have documentation that clearly substantiates the necessity of this internal referral and be prepared to produce that to the payers.

    Hope this helps.

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