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Consult question

  1. Default Consult question
    Medical Coding Books
    I would like other opinions on whether or not you would audit this and decide that it meets criteria for a consult (vs. new patient code):

    CONSULTING PHYSICIAN
    John Black, M.D.

    REASON FOR CONSULTATION
    CHRONIC KIDNEY DISEASE

    HPI

    Mrs. Doe is a pleasant XX year old female being see today for initial evlauation of chronic kidney disease. Labs available to me from her primary care physician show a baseline creatinine XXX.............

    Assessment and plan:

    List out diagnoses and plans for them

    I recommended to Mrs. Doe that she does not use RX on a regular basis.......

    No consult letter is sent but information is sent to physician listed under consulting physician above.

    What say you?

  2. #2
    Location
    Columbia, MO
    Posts
    12,531
    Default
    I see no consult here. There is no real clear cut reason as to why the consult was requested. What was the requesting doctor asking for? so I say no consult.

    Debra A. Mitchell, MSPH, CPC-H

  3. #3
    Default I don't see a consult either
    This looks like the pcp sent her to a nephrologist for her CKD. He states "initial evaluation" to me this indicates he plans on seeing her for this problem from now on.

    Which I know you can do a consult and then pick up the care for that problem but if the intent is to take over care all along there is no consult.

    Laura, CPC, CPMA, CEMC

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Where's the exam?
    Plus .. where's the exam? You need three of three (unless time is used and more than 50% of total time was spent in counseling/coordination of care).

    F Tessa Bartels, CPC, CEMC

  5. #5
    Unhappy
    I agree with no consult, no clear indication of what the consultation was for and no clear indications of findings for the PCP

  6. #6
    Smile Consult
    I agree, this is not a consult as he states she is here for her initial evaluation which indicates to me a transfer of care.

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