Practice Management Alert

Find out why both physicians should note consult request in records

When your physician requests a consultation from another physician, does she note the request in the patient's medical record?

If not, she may want to start, because the feds have declared they will be watching documentation on consult claims very carefully in 2006. 

With transmittal 788, CMS has made the documentation requirements for both physicians very clear.

Does your practice know the ins and outs of transmittal 788?

Answer:

The feds have made it clear that requests for consultation services must be noted in the medical record of both the requesting and consulting provider, according to Medicare transmittal 788.

Nuts and bolts: The transmittal, dated Dec. 20, means -that the requesting doctor must document in her medical record the consult request and the medical reason for the consult,- says Catherine Brink, CMM, CPC, president of HealthCare Resource Management in Spring Lake, N.J. New Role for Requesting Doctor -This is big, since it means that the requesting doctor has to document he is sending the patient for a consult, and the medical reason for it. This was never the case before,- Brink says.

Worse still, there is no financial incentive for the requesting doctor to perform this service.

What should we do? Make sure that all billers and physicians know the documentation requirements for consults, experts say. And whether your medical office is performing the consult or requesting it, experts recommend including the request in the patient's medical record--for compliance reasons. Document All Consult Requests  Many practices that perform consults think that the requesting doctor will take care of the documentation requirements, but this is a mistake, says Maggie Mac, CMM, CPC, CMSCS, consulting manager for Pershing, Yoakley & Associates in Clearwater, Fla.

If the consulting doctor does not note the request in his record, there is no documentation to justify a consult.  And if the consulting doctor tries to get the documentation from the requesting doctor, -there might be no request documented in the requesting physician's record,- Mac says.

Try this: Consulting physicians must always note the request for consult because they are filing the claim. That way, if the request for records is made by the payer, the documentation is on hand, Mac says.

For example, Dr. Smith sends a patient to Dr. Jones for a consultation on her knee pain. Dr. Jones provides a level-two consult, renders his opinion of the patient's condition and writes a letter to Dr. Smith explaining his findings. Dr. Jones then sends her back to Dr. Smith for further treatment.

In this instance, Dr. Smith should write words to this effect in the patient file: -Patient CC: knee pain; sent to Dr. Jones for consult to determine reason for knee pain.- [...]