Pediatric Coding Alert

Question: A patient had her past medical records, containing more than 10 years of history, sent to our doctor for review. Not all of the history related to our pediatrician (for instance, her dental charts were in the set). How can I charge for the doctor’s time reviewing these records?

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 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 doctor 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. Most payers give two points for summarizing medical history. For instance, if your physician also orders and reviews a lab result or an x-ray, 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) or a level-four established patient service (99214).