Wiki Consultations - billing a consult code

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rcollins

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When an OP report states Orthopedic Surgery Consult, does this support billing a consult code. The report does not state who requested the consult nor does it state " I was asked to consult on this pt for (reason)".

Any help would be greatly appreciated....
 
For consultations, we always look for the "Three R's " - there MUST be documentation of Request, Render (an opinion) and Response. Who requested the consultation, the doctor's opinion about the problem, and then the response to the requesting provider. Without all three of these, the service is not a consultation.
 
Agree with Kate. You must still have documentation of who requested the opinion, in addition to the reason for the opinion. For inpatient records, the common hosptial chart would suffice for the response, but for office services, there would have to be documentation of the response.
 
I'm confused ..

You write: When an OP report states Orthopedic Surgery Consult

So do you have an operative report or do you have an E/M?

Please post the documentaiton and we can give you an accurate answer.

F Tessa Bartels, CPC, CEMC
 
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