Orthopedic Coding Alert

Real-life examples help show you the way If your physician's documentation could use a tune-up, offer these tips from Brenda Chidester, CPC, CCS-P, coding compliance manager at Kelsey-Seybold Clinic, a large multispecialty physician practice in Houston, to get the doctor's dictation on the right track. Consultation request: The provider requesting a consult needs to document the request appropriately in the patient's medical record. Documentation should state that you are requesting a consult or another provider's opinion/advice about a specific problem or condition. Some examples of appropriate documentation when requesting a consult include the following: -I am requesting Dr. Jones- advice on Mr. Smith's OA of his right shoulder.- -I am sending Mr. Smith to the orthopedic department for an opinion on his knee pain.- Try not to use the generic phrase -refer to ortho.- This does not support the request for a consult but can indicate a transfer of care. If you are sending the patient to a large group and don't know which provider he will see, the phrase -consult ortho- would be a better choice. Consult provider: The rendering physician must also document appropriately. Documentation in the patient's medical record should support the consultation services provided and billed. Here are some examples of appropriate documentation when you are the rendering or consulting provider: -This patient has been sent for consultation by Dr. Johnson for worsening OA of the shoulder.- -Thank you for asking me to consult on Mr. Smith's knee problems. I would recommend ...- Do not use the term -referred- in your documentation. This term is also used for transfer-of-care patients. Be clear that your opinion or advice was requested. You must also reply back to the requesting provider in writing. For example, the letter might say, -cc to Dr. Johnson,- -send chart to Dr. Johnson,- or -fax note to Dr. Johnson.- Pre-op clearance consultations: The provider requesting pre-op clearance must document the request for the consult appropriately in the patient's medical record. Documentation needs to state that you are requesting clearance for surgery for a specific condition. Review these examples of appropriate documentation when requesting pre-op clearance: -I am requesting preoperative clearance by Dr. Jones for Mr. Smith's chronic bronchitis, as he needs to undergo a total hip replacement.- -I am requesting cardiovascular clearance by Dr. Jones for Mr. Smith's hypertension before scheduling knee arthroscopy.- Avoid using the generic phrase -refer to cardio.- This does not support the request for a consult but can indicate a transfer of care. If you are sending the patient to a large group and don't know which provider the patient will see, -consult cardio- would be a better choice. Ensure that your ICD-9 codes reflect that you-re requesting a pre-op [...]