We instruct our physicians to dictate as a consult if they were asked for an opinion. We will code it based on the payer (i.e. use new or established outpatient, or ER, or inpatient codes). Our physicians don't usually know who the insurer is, and they don't need to worry about it.
As long as the elements are there I can code the appropriate type/level of service no matter what format the documentation is in (including being in one long paragraph).
Hope that helps.
F Tessa Bartels, CPC, CEMC
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