Wiki Requesting a consultation need help ASAP

[Griffin]

I work for a Gastroenterology office. According to the guidelines you need to see the request for consultation and the reason for the consultation documented in the patients medical record. Is it sufficient for the provider to 1. write the requesting physician's name on the H and P or 2. in the physicians dictation back to the provider is it sufficient for them to state thank you for referring your patient? What documentation do you look for in the patient's medical record from the requesting physician? Need Help ASAP

 

[sjackson]

consultation documentation help

1st - never have the provider use language like "thank you for referring" this consistues that he/she is taking over care of the patient and you cannnot bill for the consult codes. use something like "thank you for allowing me to consult on your patient." instead.
2- The provider who sent you the patient needs to have requested a consult, you need to have documentation of a request in your records and you MUST report back to the primary provider who requested the exam with any findings. This can be in any form. Most practices (specailists) make up a form for other provider office to use and either fax or send back through the EMR. But at is basic all is needed is a note stating the patient to be sent to a provider or office and the reason or diagnosis to be treated. Your return letter could be a coer letter attached to the days office notes/labs/additional studies or a detailed letter.

hope this helps.

 

[FTessaBartels]

H&P

You use the term "H&P" ... this makes me think you are talking about the E/M service to "admit" the patient for a colonoscopy.

This is NOT a consultation.

Also, you need to consider whether this evaluation is global to the procedure being performed the same date, to see if it is billable at all.

Hope that helps.

F Tessa Bartels, CPC, CEMC