General Surgery Coding Alert

Question: A patient had her past medical records, containing more than 10 years of history, sent to our general surgeon for review. Not all of the history related to her current condition. How can I charge for the doctor's time reviewing these records?

Nebraska Subscriber

Answer: CPT considers reviewing records as integral to the E/M service, and you should not bill for it separately. Although CPT does not include the time associated with records review in the time component described in the E/M codes, "the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician surveys." Consequently, the service described by the E/M codes "is a valid proxy for the total work done before, during, and after the visit," CPT states.
 
On the other hand, if your surgeon reviews the records and writes a summary of those records, you may be able to raise the level of medical decision-making - this applies to the elements of tests ordered or reviewed - which may allow you to choose a higher-level E/M service when combined with the history and examination. Medicare gives two points for summarizing medical history. For instance, if your physician also orders and reviews a lab result or an ultrasound, then the data category for medical decision-making increases to multiple. If risk to the patient is moderate, this would lead to moderate-complexity medical decision-making. When combined with a detailed history and examination, you have a level-three new patient service (99203) or a level-four established patient service (99214).