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review and summarization of old records

  1. #1
    Default review and summarization of old records
    Medical Coding Books
    Can a physician take a note from his previous office note or another partner in the practice and get credit for review and summarization of old records?

  2. #2
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    What do you mean by "take a note"? Regardless, I would not count this as review/summarization of old records - it's his own or his partners "note", not a "medical record".
    Last edited by Lisa Bledsoe; 02-05-2010 at 07:42 AM.
    Lisa Bledsoe, CPC, CPMA

  3. #3
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    sometimes the physician will review a test that the patient had previously and review it and put a summary of the results in the letter or they will summarize a previous vist the patient had if it is a f/u vist to the same problem

  4. #4
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    If it's review of a lab = 1 point for review and/or order of clinical lab tests.

    As for the second part (review and summarization of previous visit f/u same problem) - that should go under dumber of diagnoses or treatment options as established problem to examiner; stable, improved = 1 point for each problem; or established problem to examiner; worsening = 2 points for each problem.

    This is my opinion...I'd like to hear what others opinions are...
    Lisa Bledsoe, CPC, CPMA

  5. #5
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    When do you think that they would get credit for the review and summarization of old records? Is that just for when they are requesting records from another physician or when the patietn brings them with from another physician?

  6. #6
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    Quote Originally Posted by jennyjlm View Post
    When do you think that they would get credit for the review and summarization of old records? Is that just for when they are requesting records from another physician or when the patietn brings them with from another physician?
    That is my interpretation.
    Lisa Bledsoe, CPC, CPMA

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