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consultation -vs- referral

  1. #1
    Default consultation -vs- referral
    Medical Coding Books
    How would you code this visit Consultation or NP?

    HPI:
    I am seeing pt in consultation today at the request of Dr M for Morbid Obesity. She is a 30yo female, who has a history of depression and P.C.O.S, who has attempted multiple forms of nonsurgical weight loss, but has been unsuccessful, etc...

    ROS: complete ROS documented

    PE: complete PE documented

    Assessment and Plan:
    The patient is a 30yo female who has attempted weight loss previously, but is now interested on our 6 months of supervised weight loss. If this is unsuccessful, she wil be interested in undergoing a LAP Roux-en-Y. We discussed both the weight loss plan as well as potenial for surgery in the future. WE answered all of her questions today andshe met with one of our nutritionists as well. We will see her back in 1 month to discuss her overall success with the nonsurgical weight loss.

    Dr X, MD

    cc. Dr M

    Thank you for your input,
    Dawn Smith, CPC

  2. #2
    Location
    Modesto, CA; Central Valley Chapter
    Posts
    225
    Default
    I would say consultation unless............the provider NEW BEFORE the patient arrived that he would be following her; if he did then it is a new patient visit IMHO.

    Thanks
    Tina

  3. Default
    I would say consult based on the documentation provided.

  4. #4
    Smile
    Consultation.....

    next visit is Established pt visit...

  5. #5
    Location
    Greeley, Colorado
    Posts
    2,045
    Default
    Doesn't there have to be more acknowledgement with the report back to the requesting MD than just a cc? It is my understanding that a simple copy of the note to the requesting MD is not adequate. Please correct me if I'm wrong...

  6. #6
    Smile Consult vs NP
    Lisa,
    I was just answering Dawn question about Consult vs NP....

    But to answer your question, YES, you have to have the THREE R'S to consider the first visit to be a Consult...

    1) Request (written) from another Doc

    2) Reason (rendering reason for Consult)

    3) Report (consult Doc needs to send to referring Doc)

    Hope this clarify my response....

  7. Default
    I know the three R's, I know that there has to be a copy of the letter / documentation that a letter was sent back to the requesting MD in the chart, but on the actual consult report, does there need to be more detailed message than cc? I have understood it to be as long as it is in the chart, the cc is alright.

    Quote Originally Posted by Lisa Curtis View Post
    Doesn't there have to be more acknowledgement with the report back to the requesting MD than just a cc? It is my understanding that a simple copy of the note to the requesting MD is not adequate. Please correct me if I'm wrong...

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