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consult letter audit

  1. Default consult letter audit
    Clearnace Sale
    I keep conflicting answers on this matter. During an external audit if by doctor charged a consultation does he need to dictate a return letter and present a copy at the time of audit OR if we have a canned letter that we attach chart notes to would that satisfy the return correspondence requirements. It would be great if I can show the doctor in black and white. I think he should dictate a letter that is one of the reasons for higher reimbursement but if I am wrong, please let me know. Thanks
    Last edited by storricellas; 03-03-2010 at 10:56 AM.

  2. Default
    Not sure if this is exactly what you are asking, but in our consultation reports it is addressed back to the doctor who made the referral and in the opening sentence he addresses the doctor by name and thanks them for his/her referral. After that opening piece he returns to business as usual for his H&P. That way you avoid the extra step of attaching and formulating a canned letter. Hope that helps.

  3. #3
    Kansas City, MO
    If you use a "canned" letter to accompany the chart note that is fine, as long as the chart notes meets all the requirements for the should support all the e/m requirements, and the recommendations, etc...
    I have seen as well, where the doctor ONLY dictates a return letter which includes his complete hx/exam/mdm and is completely supportive for auditing the e/m. This them serves as his chart note as well. I do not believe there are any requirements of how it has to look. CPT only says you need a "written report of findings/recommendations from the consultantto the referring physician"
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

  4. #4
    Default regarding consultation letter
    I have been reading on this topic and found on the codingwebu site this bit of info and I quote : "In the office setting, the progress note can not be used for the opinion. A separate document must be used to communicate back to the requesting physician. Common record in the hospital record still suffices." I have read in many other places the same thing, but in the real world what I see is a couple of sentences directed towards the referring physician thanking him for the opportunity to particpate in the care of so and so, then the chart note starts. I believe this is an incorrect way to document a letter back to the referring physician. We have not been audited yet so only time will tell.


  5. #5

    I am performing an internal audit, and would like a little bit of insight on this post. so you are stating that the original document does not stand alone as the communication back to the requesting provider? Why not? And if you have documentation on this, I would greatly appreciate if you could send that to me. Because my practice only utilizes the dictated note from the office visit, as the letter for the requesting provider. There is a cc notation at the bottom of the letter, and the requesting provider name and address is listed there.

    Thank you,
    Kristen Richard, CPC

  6. #6
    Question Consult for chart notes
    So does this work in reverse? I have a provider who uses his consult letter to augment his chart notes; he says that his EMR provider does not support a format that account for all the data, reports, etc. Can he reference the consult letter in his notes, for say HPI and ROS, instead of dictating them twice? Any comments would be helpful...Thank you

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