Consultation documentation

Question: To bill for a consult charge, there is a requirement that the “cc” has received a copy. Will the EHR process satisfy this requirement simply by being available to view in the EHR?

Answer: Proper consultation document is addressed within the content of the note. If consultations are requested or advice sought, the record should indicate to whom or where the advice is requested. The word “request” must specifically be used – that is “patient X is being seen at the request of Dr. Y”. Do not use the word “referred” as this is interpreted as a complete transfer of the patient’s care and does not constitute a consultation.