Cardiology Coding Alert

Tip: Get your cardiologist to document who the requesting physician is You may think reporting consultations accurately is a daunting task. But you can code consults with ease if you remember the three R's.

Request: Another physician, provider, patient or private insurer has to request your physician's advice or opinion. Your physician can document this request in his report back to the referring physician, experts say.

"Try to get your cardiologists in the habit of documenting who the requesting physician is and that the services he provided were a consult, not a referral of care," says Ann Scott, CPC, ACS-CA, CCS-P, business office manager at Mid-Ohio Heart Clinic in Mansfield.
 
Review: In addition to a formal request, you must have documentation that the consulting physician examined the patient and formulated a plan of care. Make sure your cardiologist's documentation meets the three key components: history, exam and medical decision-making, Scott says.

Report: The consulting physician must give the requesting physician a report of his opinion or advice. This report should include reference to the initial request, the consulting physician's opinion, and possibly a treatment plan.

For example, have your cardiologist state, "Thank you, Dr. Jones, for asking me to see Mrs. Smith today to evaluate her symptoms of chest pain. After a thorough examination, I recommend the following course of treatment," Scott says.