# Review Of Old records



## jennyjlm (Jul 25, 2011)

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?


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## jackson7591 (Jul 26, 2011)

*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


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## btadlock1 (Jul 26, 2011)

jennyjlm said:


> 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!


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## jennyjlm (Jul 28, 2011)

Thank You.


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