Part B Insider (Multispecialty) Coding Alert

Published on Mon May 26, 2014 PDF

Question: A patient had her past medical records, containing more than 10 years of history, sent to our doctor for review. Not all of the history related to our specialist. How can I charge for the doctor’s time reviewing these records?

Answer: CPT® considers reviewing records as integral to the E/M service, and you should not bill for it separately. Although CPT® does not include the time associated with records review in the E/M code descriptors, “the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys.” Consequently, the service described by the E/M codes “is a valid proxy for the total work done before, during, and after the visit,” CPT® states.

On the other hand, if your doctor reviews the records and writes a summary of those records, you may be able to raise the level of medical decision-making (MDM) - this applies to the elements of tests ordered or reviewed - which may allow you to choose a higher-level E/M service when combined with the history and examination. Medicare gives two points for summarizing medical history. For instance, if your physician also orders and reviews a lab result or an ultrasound, then the data category for MDM increases to multiple. If risk to the patient is moderate, this would lead to moderate-complexity MDM. When combined with a detailed history and examination, you have a level-three new patient service (99203) or a level-four established patient service (99214).