- Suspected problem
- Undetermined course of treatment
- Only opinion or advice sought. After the opinion, treatment may be initiated even if same encounter
- Written request for opinion or advice received from attending physician, including the specific reason the consultation is requested.
- Written opinion returned to attending physician (if a telephone call is made, both physicians must document the call in the patient record).
- Patient advised to follow up with attending physician.
- Final diagnosis is probably unknown.
- Recommended request language: "Please examine patent and provide me with your opinion and recommendation on his/her condition."
Referral Visit (which you would bill a new pt E&M):
- Known problem
- Prescribed and known course of treatment.
- Transfer of total patient care for management of specified condition.
- Patient appointment made for the purpose of providing treatment or management or other diagnostic or therapeutic services.
- No further communication (or limited contact) with referring physician is required.
- Patient advised to return for additional discussion, testing, treatment or continuation of treament and management.
- Final diagnosis is typically known at the time of referral.
- Typical veriage: "Patient is referred to your office for treament or management of his/her condition."
Hope this helps on the 1st part of your question.
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