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Thread: Valid Documentation for Consults?

  1. #1
    Join Date
    Apr 2007
    Pensacola , Florida

    Default Valid Documentation for Consults?

    AAPC: Back to School
    Can anyone help me with this ....

    if the doctor mentions in his header this is a consult requested by XXX ... then he goes on with his note , exam and findings ...

    However, the only reference back to the consulting doctor is a "cc" at bottom of page

    I am in training ...and I don't think this is enough - please someone help me to understand how to know if a "cc" to that dr. at the bottom of the exam note is enough to constitute the Consult code ?

    Shouldn't there be some mention that "he responded to Dr. So and So with his findings"

    Please advise ( P.S. these are not medicare )


  2. #2
    Join Date
    Apr 2007
    Milwaukee WI

    Default What constitutes a report to requesting MD?

    You are hung up on what constitutes a report back to the requesting MD. I would say that a CC to that physician at the bottom of the note (along with mention at the top of the note that a consult was requested by Dr X for evaluation of Y problem) would definitely count.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3

    Default consults

    3 things need to happen to bill a consult to those plans still accepting consult codes. You have to have paper documentation that dr so and so requested the exam, the consultant needs to perform the exam and transmit report to requesting p[rovider. The Requesting Provider needs to note he received the consult and comment on it. You can do verbally requested consults but you need to fax something and also get it in writing.

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