Results 1 to 4 of 4

Review Of Old records

  1. #1
    Default Review Of Old records
    Medical Coding Books
    Can a Gastroenterologist get credit for review review and summarization of old records when they are seeing a patient in the hospital and they review a colonoscopy that was done by another gastroenterologists in the same practice?

  2. #2
    Default Review
    I would think that it would receive credit so long as the documentation includes how this review is part of the medical decision making process.

    I encourage our providers to clearly state this in their plan. We review EKGs frequently. So for example "EKG obtained today compared to previous. No significant changes noted, so no changes in cardiac meds and dosages is warranted."

    Documentation such as this should receive credit

  3. #3
    Wink
    Quote Originally Posted by jennyjlm View Post
    Can a Gastroenterologist get credit for review review and summarization of old records when they are seeing a patient in the hospital and they review a colonoscopy that was done by another gastroenterologists in the same practice?
    Per CMS Documentation Guidelines (DG):

    http://www.cms.gov/MLNProducts/Downloads/MASTER1.pdf
    "The amount and complexity of data to be reviewed is based on the types of diagnostic
    testing ordered or reviewed. 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.

    Discussion of contradictory or unexpected test results with the physician who performed
    or interpreted the test is an indication of the complexity of data being reviewed. On
    occasion the physician who ordered a test may personally review the image, tracing or
    specimen to supplement information from the physician who prepared the test report or
    interpretation; this is another indication of the complexity of data being reviewed.

    DG: If a diagnostic service (test or procedure) is ordered, planned, scheduled,
    or performed at the time of the E/M encounter, the type of service, eg, lab
    or x-ray, should be documented.

    DG: The review of lab, radiology and/or other diagnostic tests should be
    documented. A simple notation such as "WBC elevated" or "chest x-ray
    unremarkable" is acceptable. Alternatively, the review may be
    documented by initialing and dating the report containing the test results.

    DG: A decision to obtain old records or decision to obtain additional history
    from the family, caretaker or other source to supplement that obtained
    from the patient should be documented.

    DG: Relevant findings from the review of old records, and/or the receipt of
    additional history from the family, caretaker or other source to
    supplement that obtained from the patient should be documented. If there
    is no relevant information beyond that already obtained, that fact should
    be documented. A notation of “Old records reviewed” or “additional
    history obtained from family” without elaboration is insufficient.

    DG: The results of discussion of laboratory, radiology or other diagnostic tests
    with the physician who performed or interpreted the study should be
    documented.

    DG: The direct visualization and independent interpretation of an image,
    tracing or specimen previously or subsequently interpreted by another
    physician should be documented."

    See the guidelines for more information on how the review of records is factored into the MDM level. Hope that helps!

  4. #4
    Default
    Thank You.

Similar Threads

  1. Review of Records
    By psiebken in forum E/M
    Replies: 1
    Last Post: 03-06-2013, 05:38 PM
  2. Review of Old Records
    By dballard2004 in forum E/M
    Replies: 7
    Last Post: 07-26-2012, 01:34 PM
  3. Review Of Old Records
    By jennyjlm in forum Gastroenterology
    Replies: 1
    Last Post: 07-25-2011, 03:51 PM
  4. Review of old records
    By trarut in forum E/M
    Replies: 11
    Last Post: 12-03-2009, 12:00 PM
  5. Review of old records
    By renifejn in forum E/M
    Replies: 2
    Last Post: 09-18-2008, 08:38 AM

Posting Permissions

  • You may not post new threads
  • You may not post replies
  • You may not post attachments
  • You may not edit your posts
  •  
Enjoying Our Forums?

AAPC forums are a benefit of membership. Joining AAPC grants you unlimited access, allowing you to post questions and participate with our community of over 150,000 professionals.

Join Now Continue Reading Without Full Access

Already a Member?

Login

Close Message

In addition to full participation on AAPC forums, as a member you will be able to:

  • Access to the largest healthcare job database in the world.
  • Join over 150,000 members of the healthcare network in the world.
  • Be a part of an industry leading organization that drives the business side of healthcare.
  • Save anywhere from 10%-50% with exclusive member discounts on courses, books, study materials, and conferences.
  • Access to discounts at hundreds of restaurants, travel destinations, retail stores, and service providers. AAPC members also have opportunities to save on heath, life, and liability insurance.
  • Become a member of a local chapter and attend regular meetings.