General Surgery Coding Alert

Question: A patient had 10 years of medical records sent to our surgeon for review. Much of the information was not relevant to the patient’s current condition or the surgeon’s treatment plan. Is there a way to bill for the surgeon’s time reviewing these records?

Texas Subscriber

Answer: You may use codes for prolonged service without face-to-face patient contact (99358 - 99359, Prolonged evaluation and management service before and/or after direct patient care; each additional 30 minutes [List separately in addition to code for prolonged service]) for records review before or after an E/M visit, in some circumstances. Your surgeon must provide appropriate documentation, including the amount of time spent reviewing the records, before you can use these codes.

Also, not all payers recognize these codes. Some commercial payers and workers comp usually pay for the codes, as do some Medicaid carriers, although Medicare does not. 

For payers that don’t pay for 99358-99359, you can account for the work in the E/M service itself.

Although CPT® does not include the time associated with records review in the E/M code descriptors, “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 (MDM) — 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 surgeon also orders and reviews a lab result or an ultrasound, then the data category for MDM increases to multiple. If risk to the patient is moderate, this would lead to moderate-complexity MDM. When combined with a detailed history and examination, you have a level-three new patient service (99203, Office or other outpatient visit for the evaluation and management of a new patient, which requires these 3 key components: A detailed history; A detailed examination; Medical decision making of low complexity) or a level-four established patient service (99214, Office or other outpatient visit for the evaluation and management of an established patient, which requires at least 2 of these 3 key components: A detailed history; A detailed examination; Medical decision making of moderate complexity).