Orthopedic Coding Alert

Question: Consult rules state that the consulting physician must send a written report of his findings and recommendations to the requesting physician. I-ve recently heard that in the inpatient setting, the report can be a part of the shared medical record rather than a separate document. Is this true?

Washington Subscriber

Answer: Yes, in the inpatient setting the consulting physician may include his report as a part of the shared medical record, rather than sending it to the requesting physician as a separate document.

The Medicare Internet Only Manual (IOM) states explicitly in Chapter 12, section 30.6.10, that the consultant must provide a report: "After the consultation is provided, the consultant shall prepare a written report of his/her findings and recommendations, which shall be provided to the referring physician."

In an emergency department or an inpatient or outpatient setting in which the referring physician or qualified nonphysician practitioner (NPP) and the consultant share the medical record, Medicare rules specify that your consulting orthopedist may document the consult report as one of the following:

1. part of a care plan written in the requesting physician's or qualified NPP's progress note

2. an order in the medical record

3. a specific written request for the consultation.

In an office setting, "the consultation report is a separate document communicated to the requesting physician or qualified NPP," according to the IOM.

In a large group practice, such as an academic department or a large multispecialty group, in which the healthcare providers often share a medical record, you may include the consultant's report in the medical record documentation and not require a separate letter from the consulting physician or qualified NPP to the requesting physician or qualified NPP. The written request and reason, as well as the consultation evaluation, findings and recommendations, should be available in the consultation report.