Racheal,
I would say the providers all need a little education on proper documentation.
10-13-12 Pt seen by the resident and documented as consultation. Report dictated by resident.
10-14-12 Patient was seen by resident and Dr. #1. Dr. #1 completed a handwritten progress note, stated she reviewed the consult from 10-13-12, noting “reviewed and agree”.
Dr. #1 submitted a consult with a date of service 10-14-12.
When a medical resident admits a patient to a hospital late at night and the teaching physician does not see the patient until later, including the next calendar day:
The teaching physician must document that he/she personally saw the patient and participated in the management of the patient. The teaching physician may reference the resident's note in lieu of re-documenting the history of present illness, exam, medical decision-making, review of systems and/or past family/social history provided that the patient's condition has not changed, and the teaching physician agrees with the resident's note.
The teaching physician's note must reflect changes in the patient's condition and clinical course that require that the resident's note be amended with further information to address the patient's condition and course at the time the patient is seen personally by the teaching physician.
The teaching physician's bill must reflect the date of service he/she saw the patient and his/her personal work of obtaining a history, performing a physical, and participating in medical decision-making regardless of whether the combination of the teaching physician's and resident's documentation satisfies criteria for a higher level of service. For payment, the composite of the teaching physician's entry and the resident's entry together must support the medical necessity of the billed service and the level of the service billed by the teaching physician.
So if Dr. 1 has this information a consult would be appropriate. But I'm guessing that progress note has a minimal amount of information.
10-15-12 Dr. #2 (pt's physician of record) made an addendum to the residents 10-13-12 consult report, stating pt seen and examined this day; does not refer to anything noted by the resident in the original report.
Dr. #2 submitted a subsequent visit dated 10-15-12.
In this situation, unless Dr 2 is the teaching physician his reference of the residents previous note is insignificant to his level of service. Because it was two days prior it would still not be appropriate to use it to support a level of service.
As an extra note:
Following are examples of unacceptable documentation:
“Agree with above.”, followed by legible countersignature or identity;
“Rounded, Reviewed, Agree.”, followed by legible countersignature or identity;
“Discussed with resident. Agree.”, followed by legible countersignature or identity;
“Seen and agree.”, followed by legible countersignature or identity;
“Patient seen and evaluated.”, followed by legible countersignature or identity; and
A legible countersignature or identity alone.
Such documentation is not acceptable, because the documentation does not make it possible to determine whether the teaching physician was present, evaluated the patient, and/or had any involvement with the plan of care.
Here's the link to CMS examples.
http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/downloads/R2303CP.pdf