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  1. Default consultations
    Medical Coding Books
    I need to know how other doctors are informing their coders on consultations that are seen at the hospital, especially subsequent days when they are the admitting dr. There is a dictated h&p for the admit date, but the subsequent days before a surgery (or even if no surgery is preformed) is always handwritten, and we must send a coworker to the hospital to copy these notes and bring back to the office so that we have proof that they actually saw the patient and we can charge. This has been proven time consuming and our drs no longer want this done. We are NOT comfortable "assuming" that they saw the pt and therefore charging the insurance company. We need to know how other offices handle this scenario. Thanks for your input.

  2. #2
    North Carolina
    Do you have the capability of becoming a user for the hospital records domain? In addition to "patient search", I also have the capability of signing on to their database and search by provider and date range. All handwritten progress notes are scanned once the patient is discharged so there could be some delay to this information.
    Rebecca CPC, CPMA, CEMC

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  3. Default
    we are able to connect to both hospitals but the problem is that they are not paperless and everthing is not scanned into their systems. The only thing we can see is what has been dictated.

  4. #4
    Milwaukee WI
    Default Consultations after admission?
    I may be mis-reading your question ... but it sounds as if your doctors are wanting to bill consultation on a patient they admitted? They can't consult for themselves.

    If you are talking about someone who is admitted for a surgical procedure, even if that surgery doesn't occur immediately, the subsequent visits are still considered global to the surgery - the decision for surgery having been made the date of admission.

    If a patient is being admitted for a non-surgical reason, then all subsequent visits are billed using subsequent visit codes 99231-33.

    As for subsequent visits, you have my sympathy; if they are handwriting and those notes are not available unless you go physically to the hospital to copy them, then that's what you must do. If the hospital isn't willing/ready to scan all materials into an electronic chart that you can then access (our does this), then you are stuck with going over there to make copies.

    As to your basic question .. our surgeons each keep a log book (although some of them use a palm pilot or similar device); they paste a patient ID sticker in the book and then write the date and what was done. Usually for the subsequent visits they just write the date and then all post-op visits performed. The admin assistant goes through the log monthly and checks against the billing system to ensure we've captured everything. If there are any discrepancies the admin asst notifies one of the reimbursement managers who researches and either submits documents to the coders, or explains to the doctor why a service is nonbillable.

    We don't code anything that isn't supported by our seeing the documentation.

    Hope that helps.

    F Tessa Bartels, CPC, CPC-E/M

  5. #5
    I'm in the situation w/ 2 of my doctors and I'm very apprehensive w/ accepting what they tell me. One dr I have to check every time, the other is pretty good and my 3rd dictates each visit into the system. That's the best method for me cause I can see it for myself. Maybe you can request that they do this.
    adrianne, cpc

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