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documentation issue

  1. #1
    Question documentation issue
    Medical Coding Books
    I work for a maternal-fetal medicine doctor who refuses to do his consults properly. He won't do any physical exam, history etc., and only spends about 5 minutes of time with each patient. He writes his consult letter to the requesting physician, but is that enough to even bill the lowest level consult? Does he have to have at least two components of the consult still? My gut is telling me the consult letter isn't enough, especially because I know he isn't doing the work (I spoke to the nurse and she said that he refuses to even come in until she has completed the history and physical) all he does is read the ultrasound results.
    I'm sure the answer is simple, and all the research I have done points to that I can't code it, but I wanted some feedback!

  2. Default
    For consults, all three of the three key components need to be met.

    Right now, that seems to be the least of the problems. The situation described is very concerning. If there's no office managment for you to turn this over to, it might be in your best personal interest to contact a health care attorney to determine what your personal liability is in case the provider is found to be fraudulent by a carrier or the government.

    Sorry to sound so severe, yet this seems serious.


  3. #3
    If it is not documented, it didn't happen. You need to get this addressed with an office manager or someone higher up and also read the article in December Coding Edge about the liability of coders.

  4. #4
    Thanks for the feedback. I know this is severe, he has already been audited, which is why I was hired. Unfortunately, I was not an expert on e/m when I started.. .I am becoming an expert on it now though. I have discovered that you can do a consult based on time only (especially for maternal-fetal specialists) but the time still needs to be documented which is still a problem for me. Cross fingers, I have to go lecture him today.

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