How to document a "verbal" request for consultations
I read alot of posts about making sure the request for consultation is in the patient's medical record. My confusion is when I read that a consultation request can be made verbally, but how do we document that.
Right now, when a physician's office calls our appointment desk and requests and appointment with one of our physicians our girls make a note that the patient was referred by "Dr _____". That note prints our on our charge ticket and then the physician dicatates that the patient was sent by "Dr ____". To me that is just not enough information.
I think we should get the request in writting. To my knowledge when an audit is done on a consultation code the referring physician's record could become part of the audit as well. If we are only getting the request over the phone then we have no proof that the referring physician documented his record appropriately.
My opinion is that we should have the referring physician's office fill out a request in writting and check off whether he/she is sending the patient for an opinion/advise or whether he/she is wanting to transfer the patient's care to us. At that point there would be no question as to what the referring physician's intentions are and intent is the big question.
How does everyone else handle this?
Christy Brown, CPC
Appalachian Orthopedic Associates P.C
Johnson City, TN