Wiki Consult documentation requirements

[cwater]

I am looking for clarification.

A consultation requires the written or verbal request for consult may be made by a physician or other appropriate source and documented in the patient's medical record by either the consulting or requesting physician or appropriate source. The consultant's opinion and any services that were ordered or performed must also be documented in the patient's medical record and communicated by written report to the requesting physician or other appropriate source.

Is an electronic referral acceptable documentation to support the request? Is a comment in the reason for visit such as ,Dr. Smith referred patient for evaluation of chronic sore throats, acceptable?
If a copy of the progress note is faxed to the referring physician, will this support the requirement for written report communicated back to the referring provider?

Thanks,
Camille Waterhouse, CPC
Pinnacle ENT

 

[Chelle-Lynn]

Is anelectronic referral acceptable documentation to support the request?

Not necessarily...

Thewords referral and consultation are not synonymous. A referral takes place when a patient is sentfrom one provider to another without a request for an opinion. The request must include that the referring provider isrequesting a consult from the provider for a specific condition, meaning that the opinion or advice of the consulting physician wasrequested from another provider.
An importantissue to remember is that consults require a request. The request and medical necessity for aconsult must be clearly documented in the patient’s medical records. The request can be received either verballyor in writing, but both request types must be documented.

Is a comment in the reason for visit such as ,Dr. Smith referred patientfor evaluation of chronic sore throats, acceptable?

Again the documentation should include that the request andmedical necessity for a consult is clearly noted in the patient’smedical records. The request can bereceived either verbally or in writing, but both request types must bedocumented.
Examplesof Correct Documentation of the Request:
Patient referredby 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, atyour request I have evaluated Jack’s COPD medical condition prior to surgery
Examplesof 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 hereprior 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 thatan opinion is even specifically requested.


If a copy of the progress note is faxed to the referring physician, willthis support the requirement for written report communicated back to thereferring provider?

Theconsultant is required to give an opinion and provide the opinion in writing tothe requesting provider. This can beaccomplished in the following manner:

The entirereport can be in the form of a letter back to the requesting provider
A cover lettercan be dictated with a copy of the report attached.
A letter cansummarize the findings and recommendations.
In a sharedelectronic medical record system, the report can be sent electronically to therequesting provider