# Dictating consult notes



## ljones315 (Sep 22, 2011)

A question has been brought up from one of the Cardiothoracic surgeons that we just started handling their billing and he is asking how does he need to dictate a consult note if the patient has Medicare. Does he still dictate it as a consult even though we cannot bill it as a consult. He is worried about the documentation not matching up to the codes that are being billed. Please advise on how other practices are handling this. I hope this question makes sense.  

Thanks for any feed back.


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## FTessaBartels (Oct 4, 2011)

*Dictate as a consult if you were asked for an opnion*

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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## ljones315 (Oct 4, 2011)

Thank you so much for the information. I will pass it along to the physicians.


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## autumn_breeze (Oct 28, 2011)

*E/M consult note ?*

Hello, for consult notes, phyisican must state the referring physician in the dictation? I have a note with no referring phyisican info but one of my physician coded it as a consult.


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## ajs (Oct 28, 2011)

sechong11 said:


> Hello, for consult notes, phyisican must state the referring physician in the dictation? I have a note with no referring phyisican info but one of my physician coded it as a consult.



Send it back with a note about what is missing for a consultation and ask for the provider to either make an addendum to the original note or re-code the encounter.


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