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documentation for consults

  1. Default documentation for consults
    Medical Coding Books
    Does anyone have any absolutes when it comes to documentation regarding consults? This is a recent scenario between my doctor and a referring doctor a the hospital. What is the wording that is necessary to ensure that this is billed correctly as a consult?

    Dr. Smith talked with Dr. Brown at the hospital about appropriate consultation requests. Dr. Brown stated a recent audit directed his practice to clarify consultations by “Thank for allowing me to see Mrs. X in consultation as well as co-manage her care.”

  2. #2
    I would be leary of coding a consult with the phrase "co-manage care". When I see that I put them down to a subsequent care day. Just because they are called into the inpatient setting doesn't mean they automatically get a consult. You can still just transfer that piece of the patients care to another provider while they are in the hospital.

    If they are truly doing a consult that is what they are being called in for, to give an opinion, not to co-manage. That is not to say they won't start co-managing but that is not the intent of the requesting provider.

    As far as absolutes on what has to be said, I have yet to see that. If someone has it I hope they post it, because believe me I have looked for it. I follow Medicare guidelines, unless a commerical carrier has their own that is different, and in the case of consults they tell you what has to be there but they don't tell you exactly what to say/document to achieve this.

    Just my opinion,

    Laura, CPC

  3. #3
    Greeley, Colorado
    I agree with Laura. If the provider is being asked to see (consult?) the patient AND co-manage care, that is a transfer of care for whatever condition the patient has that falls under the "consulting" provider's specialty.
    Lisa Bledsoe, CPC, CPMA

  4. #4
    Default the 3 R's
    At my work we go by the "3 R's":
    Request-intent of the requesting provider, make sure they are not transferring care
    Render-the consulting providers opinion(key work "opinion")
    Response-the consulting provider responds to the requesting provider

    Those are the three things we look for in a consultation. They seem to work pretty well for me when I question whether or not it's a consult or not.

  5. #5
    Hartford, CT
    I agree with the above. As far as I know neither Medicare or any other insurance has specific written guidelines for wording for consult requests. The closest guidance I could get were a couple of Ask the Contractor teleconferences. In these the moderators stated to avoid the use of the words "refer", "treatment" and "management" (ie: Thank you "referring" Mrs. Smith for consultation.). I tell my doctors that it really is just matter of semantics and they have to learn to change their vocabulary.

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