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Documenting a consult.

  1. #1
    Location
    Kansas City, MO
    Posts
    431
    Default Documenting a consult.
    Medical Coding Books
    I know just because a visit is labeled as a consultation, that doesn"t make it one....but here is all I have:

    Doc writes:

    Referred by Jackie Scmoooe, FNP

    Reason for Consult:Possible umbilical hernia

    and then into the HPI, etc.

    He also dictates a letter that says " thank you for asking me to consult on her"


    He needs to document the how and why, and from who, correct? What are some examples? Can info be inferred from the rest of the note...like why the patient is there? Or does it need to be clear "pt here at the request of dr. A, dr. A would like advice on how to treat the patient for..."

    Thanks!

  2. #2
    Default
    The performing physician (Dr. A) must be clear on who the referring provider is (Dr. B). Ex: I had the pleasure of seeing pt at my office today, at the request of Dr. B for an evaluation of (complaint/diag). That is all that is needed to bill a consult. There also must be documentation that a follow-up letter was sent to Dr. B. That can be done by documenting a cc at the conclusion of the note/letter.

    Also, if Dr. A and Dr. B are within the same group, utilizing the same tax id #, then all that is needed is the cc at the conclusion of the note/letter is sufficient for a substantial consult.
    Kristen Richard, CPC

  3. #3
    Location
    Kansas City, MO
    Posts
    431
    Default
    So in the example I gave...

    Referred by Jackie Scmoooe, FNP

    Reason for Consult:Possible umbilical hernia


    would this be enough?
    We know who sent us the patient, and why...

  4. #4
    Default
    I would say yes absolutely. I would consider that to be a consult. Just make sure there is a follow-up plan with the referring provider.
    Kristen Richard, CPC

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