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Consultation documentation

  1. Default Consultation documentation
    Medical Coding Books
    In the letter/note/written report that goes back to the requesting physician does the consulting physician have to state "the patient was sent in consultation"? Does the word consultation have to be somewhere in the documentation to satify the intent of the visit?

  2. #2
    Milwaukee WI
    Default Yes
    I instruct my physicians to do this to make it clear that the reason for the visit was a consultation requested by another provider.

    Usually the note will list the Chief Complaint as : Consultation regarding (whatever the problem is).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    Ellenville, New York
    Default Don't believe that is an absolute necessity...
    to document the word "consultation." Tessa is right that it must be clear that the physician is seeing the patient at the request of another physician, but if that is understood without that actual word "consultation", I believe that would be sufficient.

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