This may depend on payer policy. Some payers still use policy that was created for Medicare (prior to Medicare’s decision to not recognize consultation codes). This states that the consultant’s written report may be part of a common medical record or in a separate letter to the requesting physician or qualified nonphysician provider and readily available. Current Procedural Terminology instructs that there must be documentation of the request for the consultation and the report back to the requesting physician but does not directly address shared records.

Similar to copying the paper encounter note to the requesting physician, the consultant might transmit the electronic encounter note or notification of its availability in the shared system to the consulting physician. The encounter note or report should include the consultant’s advice or opinion responding to the request for consultation and information about any treatment or management by the consultant.

Currently, there are no...

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