Q&A: Documenting a medical consultation

January 23, 2009

Proper phrasing is essential when documenting a consultation; avoid using the words "referred" and "referral."

Q: During a recent carrier audit, many of our claims for consultation were downcoded to new patient visits, despite the fact that we routinely send letters to the referring physicians. The carrier's argument is that there was not enough documentation to support a consultation. What are we missing?

A: The easiest thing to remember in documenting a consultation in the medical record is something a wise instructor taught me in my first coding class-The Three R's: the Request, the Reason, and the Report. Who asked you to see the patient, why were you asked to see the patient, and what did you report back to the "requesting" physician? Eliminate the terms "referred" and "referral" when documenting a consultation. Referral implies a transfer of care, and thus a new patient visit.

An example of the difference in phrasing is "Dr. Smith is requesting a consultation for the evaluation of Mrs. Jones' abdominal pain" vs. "Dr. Smith has referred Mrs. Jones for abdominal pain." The first sentence documents that Dr. Smith is asking for an opinion and expects the "report." The second implies that the patient is being sent for treatment. Many practices routinely send copies of their office notes to the patient's primary care physician, so be careful that what you send to the "requesting" physician clearly documents your findings and recommendations.

The author, vice president of operations for Reed Medical Systems in Monroe, Michigan, has more than 30 years of experience as a practice management consultant and is also a certified coding specialist, certified compliance officer, and a certified medical assistant.