Wiki Determining complexity of data - labs and old records reviewed

[kamlambert]

I have an old 2017 E/M Training Book that states "To receive credit towards the level of E/M, the provider is required to document a summary of the old records. Simply stating "old records reviewed" without further documentation of the pertinent information found in the old records is not sufficient". Also it states "Clinical labs that are ordered or reviewed would be worth one point, whether it is one lab test or five lab tests, they are all worth just a combined total of one point. The same rule is applied for ordering /reviewing tests from the medicine section and radiology section."
Is this the old way that we used to level E/M's? Has this changed?
Can I tell my docs that stating "Old records reviewed" without summarizing still counts as a review of prior external note from each unique source?
Is ordering of each unique test or review of each unique test count per test? CBC, CMP, A1C counts as 3?

 

[jkyles]

I have an old 2017 E/M Training Book that states "To receive credit towards the level of E/M, the provider is required to document a summary of the old records. Simply stating "old records reviewed" without further documentation of the pertinent information found in the old records is not sufficient". Also it states "Clinical labs that are ordered or reviewed would be worth one point, whether it is one lab test or five lab tests, they are all worth just a combined total of one point. The same rule is applied for ordering /reviewing tests from the medicine section and radiology section."
Is this the old way that we used to level E/M's? Has this changed?
Can I tell my docs that stating "Old records reviewed" without summarizing still counts as a review of prior external note from each unique source?
Is ordering of each unique test or review of each unique test count per test? CBC, CMP, A1C counts as 3?

Hi there, that book is severely outdated. The guidelines for office/other outpatient visits changed Jan. 1, 2021. The remaining level-based E/M codes switched to the new guidelines Jan. 1, 2023. Please refer to the E/M guidelines in the current CPT manual for basic guidelines and see Medicare and specific payers for specific policies.