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Consultation documentation; 2 physicians in same practice

  1. Default Consultation documentation; 2 physicians in same practice
    Medical Coding Books
    We have Cardiologists and EP Physicians in our group now. When a Cardiologist does a Consult on a patient and then refers the patient to an EP Physician for a Consult, how much does the EP Physician have to document for the visit to meet the appropriate guidelines?? It seems that some of it would be reduntant to the Cardiology consultation letter.
    It's obvious that the EP Physician would have to touch base on the chief complaint, allergies, review of symptoms, recommendations, plan of care....
    But is it appropriate and acceptable to say "medical/surgical history, family history, social history and review of systems reviewed as per Dr A's (Cardiologist's name) Consultation done on (insert date here)"
    How much of the EP Physician's Consultation note has to be redundant to the Cardiologist's Consultation note/letter that was just done?
    We have Electronic Medical Records. The charts are all shared. Same group practice, same tax ID number for everyone...stuff like that.

    We've sent this question to our independent auditor but I want to find out for myself from other sources...

  2. #2
    Default Cardiology consult/E/M Visit
    I do have a similar question for the readers.EP is a subspecialty in Cardiology.Is it Ok to code for consult??(As far as I know within the same specialty doesn't consider as a consult/ refering one physician to another physician) Second question is since last year hospitals can't bill for consultaions. Is is OK to convert consult to clinic visit??


  3. #3
    It is OK for one specialist to request a consult from another specialist in the same group/specialty (in this case EP is a sub-specialty) if the second specialist has a certain expertise, which the first one does not have. I believe that is the case here, since the EP doc specializes beyond the general cardiologist. The documentation must meet all the requirements for the consult, so even if some of the stuff seems redundant, if it is done it should be documented. The second specialist has to get to know the case, so the information is not redundant to him/her. Your level will depend on your documentation. Remember, if it is not documented it is not done. Since they share the medical record, your requirement of reporting back is fulfilled.
    Keep in mind, all consult requirements must be met, there must be a request! If the general cardiologist sends the patient to the EP doc for treatment that is not a consult. If s/he requests an opinion on the treatment, that satisfies the request requirement.

    To Kumeena: I am not familiar with a rule that hospitals cannot bill for consults - could you please give a source for this? If you are referring to the discontinued follow-up consults for inpatient, then yes, you would use the daily care codes for that.
    Karolina, CPC, CPMA, CEMC

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