AAPC - Back to school
Results 1 to 4 of 4

Thread: Office Consult Question

  1. #1

    Default Office Consult Question

    AAPC: Back to School
    I have an office consult where the first line of the hx states "Pt is a 20 y/o male who comes in for the evaluation of abnormal screening echocardiogram" Nothing states who requested the consult. Then just goes into some add'l info.


    the letter to the referring physician (which is esentially the office visit documentation copied) is attached and "I had the pleasure of seeing your pt, xxxxx xxxx, in consultation at your request. As you know, xxx xxx comes in for evaluation of an abnormal screening echo.

    Would you could use the letter documentation for the "Request" portion of the 3 r's to bill this as a consult or would you bill as a new patient?

  2. #2


    Yes that is sufficient as long as you've met the consult requirements. As long as an audit trail is established back to the referring MD. A letter/report back with the referring MD, establishes that. and as you stated, the letter is the office visit copied (which should hold the 3/3 key components), so you're fine.
    Last edited by ARCPC9491; 10-10-2008 at 11:01 AM.

  3. #3
    Join Date
    Apr 2007
    Madison Area Chapter in Madison WI


    The use of the words "evaluation" and "referring" can point to a transfer of care. However, your provider does make reference to seeing the patient for "consultation at your request". If I audited this service, I would be more comfortable if I had a written request from the "requesting" physician. You can easily ask the requesting provider for this. I hope this helps.
    Happy Coding, Claudia

    Claudia Yoakum-Watson, CPC
    Coding, Compliance, & Reimbursement Solutions
    ccrsconsulting.com - website

  4. #4
    Join Date
    Apr 2007
    Milwaukee WI

    Default Yes, you have a consult

    Yes, you may use all the documentation available for a specific date of service, and you can use the letter to the requesting physician for proof that it is a consult. However, it never hurts to educate your physician about documentation.

    We ask our physicians to list the chief complaint as: consultation for xxx (reason). And to separately list the requesting physician. (Notice we don't use the word "referring.").

    Most of our physicians document their office consultations as a dictated letter to the requesting physician. Inpatient consultations in our hospital's dictation/transcription system have a pre-determined template of headings that includes: REQUESTING PHYSICIAN:. These headings can't be deleted, so if the dictator doesn't state the info there will be an obvious blank when s/he goes to sign the note, prompting him/her to complete that information.

    F Tessa Bartels, CPC, CPC-E/M

Similar Threads

  1. Office Visit vs Consult
    By Butterfly1972 in forum E/M
    Replies: 3
    Last Post: 01-07-2014, 01:18 PM
  2. Replies: 1
    Last Post: 01-03-2013, 10:05 AM
  3. consult or office vist
    By codedog in forum E/M
    Replies: 3
    Last Post: 06-07-2010, 04:56 PM
  4. Office Consult
    By krssy70 in forum E/M
    Replies: 1
    Last Post: 03-16-2010, 09:52 AM
  5. Replies: 1
    Last Post: 01-24-2008, 01:16 PM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts

Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?


Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.