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Documentation for consults when 2 physicians are in same group

  1. Default Documentation for consults when 2 physicians are in same group
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    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. Default
    We have several cardiologists in our practice and one EP, so of course many patients are referred to the EP. It is acceptable for the EP to add:

    "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)

    Q:How much of the EP Physician's Consultation note has to be redundant to the Cardiologist's Consultation note/letter that was just done?

    A: this depends on medical necessity, how serious is the patient's condition, is it necessary for the EP to do a detailed exam and 10 pt ROS (required for level 4 consult) to render his/her opinion and plan of treatment? also need to consider MDM...

    I hope this has helped. When you hear back from the auditor will you share their feedback?

    have a good day!

    Dolores, CPC CCC

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