Wiki MDM/Referral

[maribel8395]

I am a bit confused on where I can count a referral for E/M. Patient was seen in office for recurring UTI, decision was made to refer patient to urologist.

 

[toria11]

I am a bit confused on where I can count a referral for E/M. Patient was seen in office for recurring UTI, decision was made to refer patient to urologist.

It wouldn't be enough to simply document that the patient told the provider about their UTIs and the immediate response was "refer to urologist." It would require documentation of consideration of care and an evaluation of the problem. For example, the patient complains of UTI symptoms, provider orders a UA and confirms the infection, maybe writes a script for an antibiotic but then also refers the patient to a urologist since they are recurring.