Physicians (and coders, and insurance carriers, and patients) use "referral" and "request" interchangeably. It's an uphill battle to get them to stop this.
In your case, it sounds as if there is clear indication that a consultation was requested by the verbiage in the body of the report. I'd count it as a consult and not worry about a heading that says "referring physician."
BUT ... I would do my best to try to train the physician to use the title: Consultation requested by: Requesting Physician, MD
This would help head off any questions by an auditor (and any potential for having to refund and rebill, not to mention fines).
Maybe you can get the doctor to think of this kind of attention to the details of documentation as "preventive medicine."
F Tessa Bartels, CPC, CEMC
- ICD-10 Trainings
- Comprehensive Courses
- CPC (Certified Professional Coder)
- COC (Certified Outpatient Coder)
- CIC (Certified Inpatient Coder) NEW!
- CRC (Certified Risk Adjustment Coder) NEW!
- CPB (Certified Professional Biller)
- CPMA (Certified Professional Medical Auditor)
- CDEO (Certified Documentation Expert – Outpatient) NEW!
- CPPM (Certified Physician Practice Manager)
- CPCO (Certified Professional Compliance Officer)
- VIEW ALL CERTIFICATIONS
Coding / Billing Solutions
- Audit / Compliance Solutions
Job Experience / Apprentice Removal
News / Discussion
- Other Resources
- Book Store
- Log In / Join