decisionhealth Newsletters, Coder Pink Sheets - 2008 Issue 4 (April)
EM guideline tip: Shared record means one consult note OK
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Article Overview
This article discusses documentation and record-sharing issues for consultation services under Medicare and related payer guidance. It is aimed at coding, compliance, and billing staff who handle evaluation and management documentation in hospital, group practice, and outpatient settings. The article focuses on general documentation expectations, shared medical record concepts, and the distinction between consultation documentation and split/shared services.
Why This Topic Matters
Accurate consultation documentation affects compliance and claim support, especially in settings where multiple physicians share a medical record. The topic is important for practices that bill evaluation and management services and need to understand when written follow-up, documentation of requests, and shared-record procedures are relevant.
What You Will Learn
- How consultation documentation requirements are affected by shared medical records
- How consultation requests should be recorded in the patient chart
- How Medicare guidance addresses consultation documentation in group and hospital settings
- Why shared medical record concepts differ from split/shared service concepts
Who Should Read This
- Medical coders
- Compliance staff
- Billing staff
- Physicians
- Practice managers
- Anesthesia practices
- Pain management practices
Codes Discussed
Code Ranges Discussed
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