Wiki Amount and/or Complexity of Data Reviewed

[Chelsea1]

Have a question regarding Lab ordered and/or reviewed vs. Review and summary of old records (This is for a specialty physician sending dictated letter to PCP)

How far back can you consider "old records?" I have patients that have had labs done just a few months ago and when the physician reviews them, I don't know if I should use lab reviewed vs. review old records. Sometimes if the patient is coming in frequent for another reason the physician will review the labs again in his note that is sent to the PCP. Do I give another "point?"

Thank You

 

[thomas7331]

"Review of old records" is discussed in a little more detail in the official CMS guidelines. Taken in context, the intent of this is to take into consideration a provider's decision to obtain, and work in reviewing, additional records from outside sources 'to supplement that obtained from the patient'. I would not count this for the review of the patient's existing chart for past history - that is a normal part of taking the patient's history in any encounter. In my opinion, the extra point for old records is intended when, for example, a provider requests a copy of the chart from a hospital stay or records of tests done at another institution because the patient's problem is sufficiently complex that this additional information is needed for management of the problem. Similarly with the data point for review of labs, this should be a part of the MDM, so the lab work that is ordered or reviewed should be pertinent to the current management of the patient's problem, and not simply a review of what was already documented in the chart from past encounters with the same provider.

 

[dpogwizd]

Medical Records Requests

While this post pertains to the documents the provider is reviewing, I have a question regarding how much of the patients medical record is sent when a request is made. As I have looked in several areas on the forum, there does not seem to be anyone topic that relates so I am posting here and hope it is appropriate. I have been told to only send our facility records, (e.g. progress notes, lab results, psych notes, procedure notes and any results that have been sent back to our provider due to a contract.) If the patient were to obtain tests at facilities other then who we have a contract with (meaning they bill our facility for the services done), I was told that those results are not to be sent and the entity requesting the records can contact that facility directly for the records. I feel that if we ordered the test, no matter where the patient goes and the results are sent back to us, we should be sending those as well. Please help.