How do I document a consultation visit?

Four things should be documented when a consultation is performed:

  1. The consultation request,
  2. The reason for the request,
  3. The services rendered,
  4. The report from the consultant physician.

What are the 3 R’s for consultation?

request, rendering
The “Three R’s of Consultations” include documentation of the request, rendering of the service and report back. The report should be some formal communication to the requesting professional.

Does consultation in this scenario need to be documented?

A request for a consultation, along with the need for a consultation, must be documented by the consultant in the patient’s medical record and included in the patient’s medical record of the requesting practitioner. This opinion, along with any other service provided, is documented in the patient’s health record.

What is required for a 99204?

For a 99204, all three major criteria (history, physical exam and medical decision making) must be met. For a 99204, the physical exam must cover at least 18 bullets from at least nine systems or body areas. A 99214 requires at least 12 bullets from at least two systems or body areas.

What does a consultation include?

During your consultation, the attorney will ask about the issues in your case and discuss the merits of the actions and the various ways you can proceed. There will then be a mutual selection process.

What are the requirements to bill a consultation?

CPT® defines a consultation as “a type of service provided by a physician whose opinion or advice regarding evaluation and/or management of a specific problem is requested by another physician or other appropriate source.” To substantiate a consultation service, documentation must include three elements: a request, a …

What is a consultation code?

A consultation, as defined by the CPT manual, is an evaluation and management service provided at the request of another physician or appropriate source to either recommend care for a specific condition or problem or to determine whether to accept responsibility for ongoing management of the patient’s entire care or …

Can I use a 24 and 57 modifier together?

E/M service resulting in initial decision to perform major surgery is furnished during post-operative period of another unrelated procedure, then the E/M service must be billed with both the 24 and 57 modifiers.

What is 62 modifier used for?

Modifier 62 The individual skills of two surgeons (each in a different specialty) are required to perform surgery on the same patient during the same operative session.

What are the 4 examination levels?

Similar to the levels of history, there are four levels of physical exam documentation:

  • Problem Focused.
  • Expanded Problem Focused.
  • Detailed.
  • Comprehensive.