Consultation with a Medical Health Care Professional Template

Consultation with medical health care professional.

Patient medical history reviewed.

Consultation Details:
Medical provider consulted: Medical provider consulted
Practice/Hospital: Practice/Hospital
Date of consultation: Date of consultation
Method: Method

Reason for Consultation:
Dental procedure planned: Dental procedure planned
Medical concern: Medical concern

Medical consultation support: Medical professional contacted and reason
Discussion details: Medication/medical issue discussed and recommendations received
Clearance/instructions: Clearance status and medication instructions

Information Requested:
Medical clearance for dental procedure.
Antibiotic prophylaxis recommendations.
Medication management.
Bleeding risk assessment.
Anesthesia considerations.

Patient Medical Information Discussed:
Current diagnoses: Current diagnoses
Current medications: Current medications
Recent labs/tests: Recent labs/tests
Recent procedures/hospitalizations: Recent procedures/hospitalizations

Recommendations Received:

Medical Clearance Status:
Cleared with modifications: Cleared with modifications

Medication Instructions:
Continue medications: Continue medications
Hold medications: Hold medications
Resume medications: Resume medications

Written documentation received and filed in patient chart.

NV: Next visit

Documentation requirements

A defensible D9311 chart note has to prove a real provider-to-provider conversation happened, what was discussed, and how it changed the dental plan. Required elements:

• Identity of the medical provider consulted — full name, credentials (MD, DO, NP, PA, RN), specialty, and practice/hospital. "Dr. Smith's office" is not enough.
• Provider NPI — capture when available; many payers and audit reviewers expect it for D9311 specifically because it's the cleanest proof the consult was with a credentialed clinician.
• Date and time of the consult — the date the conversation occurred, not the date you saw the patient.
• Method of communication — phone, secure portal message, fax, written letter, or in-person. If by phone, note the call duration; if by message, that the written response is filed in the chart.
• Reason for the consult — the planned dental procedure or the finding that triggered the call (e.g., "planned extraction #18, #19, #30, #31; patient on apixaban 5 mg BID for atrial fibrillation").
• Specific medical information discussed — current diagnoses, current medications with dose and frequency, recent labs (INR, HbA1c, platelet count, CBC, kidney function), recent procedures or hospitalizations, and any new concerns identified.
• Clinical question asked — what you wanted the medical provider to answer (continue/hold anticoagulant? safe to extract? prophylactic abx needed? clearance for sedation?).
• Recommendation received — the medical provider's actual response in their words, including any conditions ("OK to proceed if INR <3.0," "hold apixaban for 24 hours pre-op and resume that evening," "no antibiotic prophylaxis needed per current AHA guideline," "prefer to defer extraction until patient is 3 months post-stent").
• Clinical decision impact — how the recommendation changed your dental plan. This is the line auditors look for. "Discussion confirmed plan unchanged" is acceptable; "Per Dr. Patel's recommendation, deferred extraction 30 days; will reassess after dual antiplatelet therapy ends" is stronger.
• Written confirmation — when the consult is by phone, request and file a written follow-up (faxed letter, portal message, or written summary signed by the medical provider). Several payers and state Medicaid plans require the written documentation in the chart for D9311 to pay.
• Patient communication — that the patient was informed of the consult outcome and consented to the revised plan.
• Provider signature and date.

D9311 is a "by report" cognitive code in spirit — the written note carries the entire claim. Pre-print boilerplate that doesn't identify the medical provider, the actual question, and the actual recommendation is the single biggest reason claims fail review. Cite the provider's own words when they're brief and unambiguous; that closes the loop.

Common denial reasons

The most common reasons D9311 is denied, downgraded, or audited:

• Missing identity of the medical provider — no provider name, no specialty, no practice; the auditor can't confirm the consult occurred
• Missing or vague NPI — carriers increasingly expect NPI capture for D9311; absent NPI is a flag on Medicaid policy reviews
• No date of the consult — the date the conversation actually happened must be in the note
• No method of communication — failure to document phone, secure message, fax, or in-person
• Generic, copy-pasted consult language — "Spoke with PCP, no concerns" without the actual question or recommendation reads as boilerplate and is rejected
• No impact on the dental plan — the recommendation is documented but the chart never says how it changed (or didn't change) the planned treatment
• No written follow-up filed — phone consults submitted without the subsequent written confirmation from the medical provider
• Bundled into the same-day procedure — D9311 billed on the same date as the extraction/implant/sedation it supported and bundled by the carrier into the global value
• Coverage carve-out — plan simply doesn't list D9311 as a covered benefit; documentation is fine, but reimbursement isn't available under that contract
• Same-day conflict with D9310 — both consult codes billed on the same DOS; only one consult code pays per encounter
• D9311 used for routine MH review — billing the code for the standard medical-history update at every recall; this is part of the evaluation code, not a separate consult
• D9311 used for staff-to-staff verification — front-desk insurance verification or RN-to-RN scheduling calls are not the dentist-initiated consult D9311 contemplates
• No patient consent / awareness — chart doesn't reflect that the patient knew the consult was happening or was informed of the outcome

Related templates