Wiki Billing for new patient medical record review

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Lea,
The provider would be able to count this work as part of the the amount and/or complexity of data reviewed. If previous records were reviewed yes that can be counted as well as the decision to get the pt's records from another provider or entity. Also the review and summarization of old records. Important that this work has to be charted in the office note always. Do you use an audit sheet or need direction on where to find one?
 
Some payers may cover prolonged services without direct patient contact. These codes were developed with this type of work in mind. CPT states, "This service is to be reported in relation to other physician or other qualified health care professional services, including evaluation and management services at any level. This prolonged service may be reported on a different date than the primary service to which it is related. For example, extensive record review may relate to a previous evaluation and management service performed earlier and commences upon receipt of past records. However, it must relate to a service or patient where (face-to-face) patient care has occurred or will occur and relate to ongoing patient management. A typical time for the primary service need not be established within the CPT code set."

This work could also be included in chronic care management time or care plan oversight if the patient's condition and services rendered meet the requirements for reporting those services.
 
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