# Summarization of old records



## smeetze (Jun 30, 2010)

If you are a specialist and you review old records from a patients PCP, in order to get credit for it, do you have to summarize the entire record that is sent by the PCP or just the pertinent information that pertains to why the patient is being sent to you (your specialty)? 

I am just trying to figure out if you have to summarize the entire record from the PCP. If so that could possible be a few pages just in summarization.

Thanks for any help on clarification!


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## FTessaBartels (Jul 1, 2010)

*Pertinent*

I would give credit for pertinent info only.

E.g.  Patient has a lesion on finger. Pt has seen PCP twice for this, with cryo treatment, but lesion returns. Pt now goes to see a dermatologist and that specialist requests medical records. If the specialist isn't specific in his/her request it's possible that the PCP office will send EVERYTHING. (I personally have had the same CPC since 1972!)  Does the dermatologist really care that the patient had bronchitis in 1983?  Is the dermatologist even going to read past the note where the lesion is first noted? No and not likely. 

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## smeetze (Jul 13, 2010)

Thanks Tessa! That does help and makes sense to me!

SMeetze


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## Love Coding! (Jul 14, 2010)

*Hello Tessa*

I also have a question in regards to "Summarization of old records", our patients bring their records with them when they are a new patient.  We specialize in Nephrology.  My question is, included with that they have labs that were previously done and ultrasounds that were previously done.  Would all this information be bundled together under that statement?  Or would the physician get 1 data point for reviewing tests under the radiology section and 1 data point for reviewing clinical lab results?

Thank you 

dscoder74


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## FTessaBartels (Sep 29, 2010)

*Depends*

If a patient shows up with ALL his/her medical records, I'd be inclined to give credit only for summarizing old records.

I'm guessing that for a new patient YOUR doctor will want to order a new set of labs or ultrasounds - he gets 1 point for ordering OR reviewing, so that would cover that data point.

Hope that makes sense.

F Tessa Bartels, CPC, CEMC


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