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Thread: Inpatient Consults must be dictated?

  1. #1

    Default Inpatient Consults must be dictated?

    AAPC: Back to School
    I am having a challenge with some of my physicians. Somewhere along the way one of them has been told (not by me) that if they do a level 3 or less they don't have to dictate inpatient consultations. ??!!

    When they provide inpatient consultations they are documenting in the hospital records. Often the referring physician is a hospitalist and they claim they don't have an office to send anything to so why do they have to dictate? The hospital chart is their chart. I am not familiar with exactly how hospitalists prefer documentation, if they have other charts, etc. I do have access to the scanned hospital record.

    per CPT guidelines the consult "...must also be documented in the patient's medical record and communicated by written report to the requesting physician... " I have always interpreted that to be dictated. My physician is saying it doesn't SAY dictated; therefore, why can't written suffice?

    Does anyone have any recommendations on where I can find any written guidelines that refer to dictation? Has anyone come across this situation or have any guidelines in their office?

    Please let me know.

  2. #2
    Join Date
    Apr 2007


    unfortunately, there are no guidelines (that I know of) for how documentation must be done. It can be either handwritten or typed. There could however be guidelines set forth by the hospital medical records department which is where he could have heard that.

  3. #3


    If your providers are expecting to charge for their consults (regardless of level), they must document their service according to consultation guidelines (Request, Render, Respond). It may be a hospital policy that the level 4-5 consults actually be "dictated" for transcription purposes. Maybe levels 1-3 can be "handwritten" in the chart. Is this what you mean?


  4. #4
    Join Date
    Apr 2007
    Garden State Chapter, Cherry Hill, NJ


    in the CMS IOM 100-04, Chapter 12, secion 30.6.10, part F, it states:
    "Consultation Report
    A written report shall be furnished to the requesting physician or qualified NPP. In an emergency department or an inpatient or outpatient setting in which the medical record is shared between the referring physician or qualified NPP and the consultant, the request may be documented as part of a plan written in the requesting physician or qualified NPP’s progress note, an order in the medical record, or a specific written request for the consultation. In these settings, the report may consist of an appropriate entry in the common medical record.
    In an office setting, the documentation requirement may be met by a specific written request for the consultation from the requesting physician or qualified NPP or if the consultant’s records show a specific reference to the request. In this setting, the consultation report is a separate document communicated to the requesting physician or qualified NPP.
    In a large group practice, e.g., an academic department or a large multi-specialty group, in which there is often a shared medical record, it is acceptable to include the consultant’s report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP to the requesting physician or qualified NPP. The written request and the consultation evaluation, findings and recommendations shall be available in the consultation report."

    I hope this helps! Oh, BTW, the link to this citation is http://www.cms.hhs.gov/manuals/downloads/clm104c12.pdf

  5. #5

    Smile Perfect!

    Thank you all so much! That helps me tremendously.

    I did check with the hospital my physicians are on staff at, and it is part of the bylaws they are to dictate.

    Yeahh well we know how that goes.

    Thanks for all your help.

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