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House Medicine Consult

  1. Default House Medicine Consult
    Medical Coding Books
    Not certain if this should be a consult or hospital visit.
    Neurologist requests "consult" from house medicine physician for medical management.
    The consult note was not dictated so copies of the consult were not sent to the referring provider however, consult notes are in the hospital chart. Can that be considered a consult without actually sending a report to the referring provider?
    Also can this really be considered a consult if house medicine ends up following patient during his/her admit stay?

    My thoughts are that this should be billed as an initial hospital visit. Any suggestions?
    Be Blessed!
    Zaida D. McGarry, CPC

  2. #2
    Location
    Milwaukee WI
    Posts
    4,466
    Default Hospital consult don't need separate report
    Inpatient consultations do not require that a report be sent to the requesting physician, as there is an assumption of a shared medical record for the inpatient.

    So, not sending a report is not an issue in your scenario.

    However, I think you may be correct that this is not a consultation at all. If I am interpreting you post correctly, the Neurologist (presumably the admitting physician) is not asking for advice on how to treat, but is asking that the hospitalist manage the issue. This is not a request for consultation but a trasnfer of care. The hospitalist would code the appropriate level Subsequent Hospital Visit. It would not be an Initial Hospital visit as the Neurologist who admitted the patient would have used that code.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. Default shared medical record
    So the letter or report is not a requirement for inpatient consults? You know the next question...is that written somewhere?

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Yes
    Quote Originally Posted by efuhrmann View Post
    So the letter or report is not a requirement for inpatient consults? You know the next question...is that written somewhere?
    Yes, it is, but I don't have the reference off the top of my head. This question has been asked and answered several times in the forums ... check under the E/M forum ... you'll probably find it there.

    Rebecca Woodward ... where are you with your quick links!

    F Tessa Bartels, CPC, CEMC

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