What to do with a 5 year old child in coding

You are a coder in a cardiology practice. A five-year-old child is referred to the office for evaluation of a possible heart murmur. There is no written request for this evaluation, but your physician insists that you bill this visit as a consultation. How would you handle this situation? Then consider a time when you had to make a difficult professional decision. What dilemma(s) were you faced with and how did you resolve the situation?

It is a consult!

The doctor's note should state "referred to me by Dr X for eval of heart murmur." You can also call the Primary doc and ask for a copy of the note or send them a form to fill out.
I am not sure what the second part means....are you working on a psychology PhD?

what to do?

It sounds as if you don't think you are being asked to code compliantly.

I would get the primary care physician's note: it sounds like a consult. 5 year old's don't self refer for heart problems: someone notices an abnormal sound/rhythm/test result. So, I"m not sure why you are reluctant.t

Maybe you aren't concerned about being asked to code in a way you don't agree with. If you are, take your concerns to your supervisor, but be very sure you have the citations and facts. Consults, according to CPT, can be "to determine whether to accept care" . Check the 2010 editorial comments for their definition of a consult. If you find citations to support your stand, talk to your supervisor or the managing MD.