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Review of old records

  1. Question Review of old records
    Exam Training Packages
    Hi all I'm trying to find some reference material discussing review of old records as a data element. I've read the Medicare DG's and it's just not that clear to me. Do the "old records" have to be requested from another provider or can they be old records from our chart that the physician reviews and summarizes in the progress note?

    We are an oncology practice and our physicians will summarize old biopsy findings, old scan results, etc. I'm not sure whether I can legitimately give credit for review of old records or not.

    Thanks,
    Tracy
    Last edited by trarut; 11-23-2009 at 10:28 AM. Reason: reworded my request

  2. Default Bumping...
    ...in hopes that someone will have some info

  3. #3
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    Ellenville, New York
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    Default
    I am reviewing the E/M services guide from CMS and it does not state from where the old records must be requested. It does state that this information should "supplement information obtained from the patient." Given the description you have of reviewing old biopsies, scans, etc., those sound more like they would also be under review of lab tests, radiology tests or procedures from the medicine section. If it is simply a review of the records, also keep in mind that the documentation does have to state more than just "review old records." I have used old record review that were records in the office to count toward this as long as the documentation is sufficient.

    Hope this helps.

  4. #4
    Default
    I wouldn't count it. Though the guidelines don't say it outright they certainly imply the old records are not your own.

    "A decision to obtain and review old medical records and/or
    obtain history from sources other than the patient increases the amount and complexity of
    data to be reviewed."

    If the records are yours, you don't have to obtain them from a source, you just flip to the back of the chart. Also, someone in your office should have already gotten credit for ordering/reviewing those tests at some point.

    Just my opinion,

    Laura, CPC, CEMC

  5. #5
    Red face
    Now I'm confused. The documentation guidelines does not state where the old records should be coming from. Reveiwing the patients medical record and documenting what was the physician findings, I thought was sufficient for counting that element. Ex: Pt was diagnosed in 1997 with right breast DCIS, and is status post excision with subsequent radiation therapy. I would consider that as reveiwed old records??? So instead, what would I could that as???? Thanks
    Kristen Richard, CPC

  6. Default
    Thanks for the input I understand what MnTwins29 and Laura are both saying about the review of old records but for us, it's not always as simple as flipping through the chart to look for a few test results. As oncologists, my physicians are managing multiple sets of data for our therapy patients in order to make ongoing decisions about their treatment regimens. They should be credited accordingly--I'm just not sure where or how to do it properly.

    That said, right now I rarely give credit for review of old records and usually only for new patients. We are currently reviewing our internal processes and I'm trying to gather as much info as I can before they start asking questions that I can't completely answer. I can't argue CMS guidelines with them because they will not accept it as an industry standard, no matter how often I point out that the majority of the other carriers are following CMS guidelines for E/M (in my experience so far anyway).

  7. #7
    Unhappy
    I agree with you regarding the mulitple sets of data. I too work with oncologists, and they are always reviewing path reports, radiology reports, previous surgery op notes, etc. So again, I usually count that reveiw of old records due to the amount of data they are reviewing. If you find anything, please share, this is still confusing me, as I have been counting that all along

    Thank you,
    Kristen Richard, CPC

  8. Default
    I understand, Kristen!! Data is such a gray area that it's hard to find any guidance at all.

  9. #9
    Default
    My thing is sometimes the data they are reviewing does not fall in the criteria of lab, radiology, or the medicine section of CPT. I have no other choice but to use the reveiw of old records.
    Kristen Richard, CPC

  10. Default
    Believe me, I understand I've got the same issue here. I just need to know it will stand up to scrutiny by an auditor if I use it that way.

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