# Review of old records



## trarut (Nov 20, 2009)

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


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## trarut (Nov 23, 2009)

*Bumping...*

...in hopes that someone will have some info


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## MnTwins29 (Nov 25, 2009)

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.


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## LLovett (Nov 30, 2009)

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


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## krssy70 (Nov 30, 2009)

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


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## trarut (Dec 1, 2009)

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).


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## krssy70 (Dec 2, 2009)

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,


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## trarut (Dec 2, 2009)

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


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## krssy70 (Dec 2, 2009)

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.


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## trarut (Dec 2, 2009)

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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## bettze1947 (Dec 3, 2009)

*My 2 cents worth*

During a webinar with Cahaba MAC prior to our transition to J10, this subject was brought up.  The Medical Drector stated that in order to be documented correctly the notation of "reviewed old records" or "see patient chart" or referring to a date of a previous visit, "see notes from xx-xx-xxx", would not be sufficient.  There would be a need to compare an old record to a current finding, symptom or medicine regimin.
      He stated that the record should be detailed, as in, "reviewed lab results from xx-xx-xxx, there is no change from the RBC, WBC, etc from tdays results. It is noted the hematocrit level has improved from 9 to 12.3, etc"  For an x-ray, "I reviewed the x-ray films A&P chest dated xx-xx-xxx. There appears to be a shadow in the LLQ of the right lung and concur with the radiology report that a bronchoscopy is indicated", or "reviewed xray films from xx-xx-xxx and in the absence of any symptomology from pt, feel that there is no acute process at thyis time, but will repeat test in 6 mos to see if any changes".
       There was a clear distinction made between reviewing interps from the actual film or lab test results.  It was also noted that if records were reviewed and documented, that they had to be included in the chart for that DOS.  Each E&M had to be able to stand on its own in the event of an audit.  To refer to  past date records, tests, etc, without including specifics made it impossible for a comparison to be made and inference would not support being counted.
        As I audit, I am looking for those specifics.


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## trarut (Dec 3, 2009)

What a great summation, betteze1947--thanks!!  Did he say anything specifically about whether the old records must be from an outside provider?


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