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Review of old records

  1. #11
    Red face My 2 cents worth
    Medical Coding Books
    During a webinar with Cahaba MAC prior to our transition to J10, this subject was brought up. The Medical Drector stated that in order to be documented correctly the notation of "reviewed old records" or "see patient chart" or referring to a date of a previous visit, "see notes from xx-xx-xxx", would not be sufficient. There would be a need to compare an old record to a current finding, symptom or medicine regimin.
    He stated that the record should be detailed, as in, "reviewed lab results from xx-xx-xxx, there is no change from the RBC, WBC, etc from tdays results. It is noted the hematocrit level has improved from 9 to 12.3, etc" For an x-ray, "I reviewed the x-ray films A&P chest dated xx-xx-xxx. There appears to be a shadow in the LLQ of the right lung and concur with the radiology report that a bronchoscopy is indicated", or "reviewed xray films from xx-xx-xxx and in the absence of any symptomology from pt, feel that there is no acute process at thyis time, but will repeat test in 6 mos to see if any changes".
    There was a clear distinction made between reviewing interps from the actual film or lab test results. It was also noted that if records were reviewed and documented, that they had to be included in the chart for that DOS. Each E&M had to be able to stand on its own in the event of an audit. To refer to past date records, tests, etc, without including specifics made it impossible for a comparison to be made and inference would not support being counted.
    As I audit, I am looking for those specifics.

  2. Default
    What a great summation, betteze1947--thanks!! Did he say anything specifically about whether the old records must be from an outside provider?

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