Wiki Consult codes

[torih@nwurology.com]

Hello,

I have been doing some research on consult codes and I understand that the requesting provider must request the consult, state the reason and the consulting provider must report back. However, with EMR's I don't see any letters from providers! I see chart notes being faxed back and forth and basically the request and report being reported in the "Plan" portion of the chart note. Is that sufficient documentation for a consult?

Thanks!
Tori

 

[Chelle-Lynn]

The consultant is required to give an opinion and provide the opinion in writing to the requesting provider. In an EMR system, the report or medical records can be used in place of an official letter as long as the below noted documentation is contained within the medical records.

Documentation Requirements:


1. Is there documentation from the requesting physician stating that a consult is being requested? (Physician Name)
2. Is the reason for the consult documented? (Consult for what?)
3. Was an examination completed? History, examination, medical decision making?
4. Did the medical records contain physicians findings and or recommendations written in manner as to report back to the requesting physician?

 

[torih@nwurology.com]

Hi Chelle-Lynn

1) We usually receive chart notes from the requesting provider and in their notes, they are stating for the patient to see Urology. Sometimes they specifically say our office, other times, it just says refer to Urology.

2) Our provider will state "patient referred for evaluation of XXX".

3) Yes...full exam, HPI and MDM documented.

4) Our chart notes (that are sent back to requesting provider), show in the plan: We will continue XXX medication, PSA in 3 months, f/u with me in 3 monthsl, etc.

Tori

 

[Chelle-Lynn]

Examples of Correct Documentation of the Request:

Patient referred by Dr. Jones for my evaluation and opinion of their COPD
Dear Dr. Jones, thank you for requesting my opinion about Jane?s headaches.
Dr. Jones, at your request I have evaluated Jack?s COPD medical condition prior to surgery



Examples of Incorrect Documentation of the Request:

Dear Dr. Jones, thank you for sending me Jane for her headaches.
It does not state request for opinion.
Jack is a 55 yr. old male referred to me for the treatment of his back pain.
It does not state who is requesting the opinion
Jane is here prior to the surgery for pre-op clearance.
Medical necessity for the pre-op is not stated
It does not state who is requesting the opinion or that an opinion is even specifically requested.


The conclusion or assessment needs to indicate the final determination:

Is the specialist taking over the care of the patient?
Is the specialist providing an opinion or recommendation only?
etc.

It is good to use some sort of wording in the assessment such as "Thank you Dr. Jones for referring this patient for a consult...."

 

[bungalowgirl]

I would also watch the word 'referred' in exam language... many hmo's require a referral to a specialist, and a 'referral' does not automatically mean a 'consult'... if it appears to be a transfer of care, that is NOT a consult... for example, a pt is seen for nosebleeds at local ER, then told to follow up w/ENT office. That is a transfer of care, since the ER Dr does NOT expect to hear back from the ENT or follow up with the pt for his nosebleed...

 

[arrana]

Tori, I am having the exact same issue with our new dermatologist. He writes in the HPI - "sent from PCP for evaluation of...", and then faxes a copy of the visit note to the PCP. The PCP is at the same practice.

HPI, Exam, and MDM are all excellently documented. He often treats during the first appointment.

Here is a sample note:

Subjective:

Chief Complaints:
1. Rash.

HPI:
General:
41 yo male with no personal hx of skin CA sent from PCP for evaluation of:
A) red rash on the neck x years, getting more obvious
B) brown spots on the back x years, growing and increasing in number.

ROS:
pt denies fever, chills, unexplained weight loss, changing skin lesions.


Objective:

Vitals: (Initials) km, BP 126/78, Cuff size adult, HR 90, RR 16, Temp 98.1, Site oral, Ht 90, Wt declined, WT w/o shoes decline, Pain Scale 0, Oxygen sat % 96.

Examination:
General Exam:
FULL BODY SKIN EXAM was declined by the patient. A waist up examination was performed including scalp (including hair inspection), head (including face), lips but not teeth and gums, neck, chest, abdomen, back, right upper extremity, left upper extremity.
General Appearance of the patient is well developed and well nourished.
Orientation: alert and oriented x 3.
Mood and affect: in no acute distress
Findings in the above examined areas were normal with the exception of the following exam descriptions below
-ill defined erythematous patches with telangiectasias and slight hyperpigmentation in photodistribution of the lateral necks bilaterally
-scattered light to dark brown stuck on papules on the trunk.



Assessment:

Assessment:
1. Civattes poikiloderma - 709.09 (Primary)
2. Seborrheic keratoses - 702.19

Plan:

1. Civattes poikiloderma
Notes: Poikiloderma of Civatte
-reassurance provided on the benign nature of this rash
-lack of effective treatment options discussed
-Pulse dye laser discussed as only effective treatment (pt understands this is not covered by insurance).

2. Seborrheic keratoses
Notes: seborrheic keratoses on the back
-reassurance provided on the benign nature of these lesions.

3. Others
Notes: note faxed to PCP.


Follow Up: prn


I don't feel that this qualifies as a consult but as a referral/transfer of care.
My real question is: Does the progress note being faxed back to the requesting provider constitute a written report.

Thanks,
Arrana Ashton, CPC

 

[krwheato]

consult report

I was wondering the same. If a CC to the physician at the top of the note could be considered as a report?
Should it also state Dr.ABC thank you for letting me see this patient for said diagnosis, and a copies sent to Dr.ABC at the top of the note?

Thank you!