I have a couple questions relating to a Family Physician's office. I do quarterly audits for each physician and just recently met with our family physician within our group.
Question #1 Upon asking the physician if he ever does any consults, he said, "No, but I get asked a lot to do pre-op clearances, so in my mind that is a consult." My question is, as long as he is meeting the consult documentation requirements, can we code this as a consult?
Question #2 Along with all the auditing, I have taken on an additional task of creating forms that better meet the physician's needs for documentation reasons. As I'm creating these forms, in which the patient will fill out a portion of, I am thinking the patient really needs to sign the form. Otherwise, that information could belong to anyone. My question to this is, upon the patient signing the form what would be a proper verbage to use on the form so the patient knows what they are signing for. I already have one simple sentence of "I authorize the provision of reasonable and proper medical care by today's standards." And then the patient would sign. Is that good enough, or should something else be added? Any suggestions would be great.
Tiffany Fischer, CPC, CEMC