Gastroenterology Coding Alert

Although checking for a request, a written report and a reason for the request is always a good idea when reporting consultation codes, most carriers relax their requirements when physicians share charts for intra-practice referrals.
 
A common medical record both in the hospital and in a group medical practice is sufficient as a report. Do not forget though if you are not using a common medical record, if it is not a group practice, or if it is not an inpatient consultation, there needs to be proof that you sent the report back to the requesting physician. This "report" can be done verbally, says Michael Weinstein, MD, a gastroenterologist in Washington, D.C.
 
Here are a couple of reports with first sentences that do not meet the criteria for a consultation:
 
1. Dear Dr. Jones: Thank you for sending me your patient. I see a lot of patients who are sent for their bloody stool. The request for the opinion is not documented. It is clear that the patient was sent, but it is not clear that there was a request for an opinion.
 
2. The patient is a 55-year-old male referred to me for treatment of his abdominal pain. There is no request documented for an opinion because you do not know how the patient was sent or who referred that patient.

Here are two examples of consult reports that successfully meet the criteria for the documentation in the first sentence or two:
 
1. Dear Dr. Jones: Thank you for requesting my opinion about Betsey's constipation problem. While her stool is uncommonly dry, the constipation is not indicative of a larger problem. Here, we clearly have the documented request. We also have the rendered opinion - standard constipation. And we have sent the report back to the requesting physician, as indicated by the letter.
 
2. For a preoperative examination consultation: Dear Dr. Jones: At your request I have evaluated Ms. Hipp's medical condition prior to surgery. I find her medical problems to be A, B and C, and she is cleared for surgery. You have the documentation of the request, and the physician has rendered an opinion.