Wiki Review of Medical Records

[evelynetorres]

Are there any codes that can be used to review medical records received for patients who have transfers care to our site? We are receiving tons of records from other facilities and the providers are spending up to 30 minutes reviewing these records prior to the patient being seen. Is this a billable service?

 

[FTessaBartels]

Part of MDM

It's not separately reportable. But be sure it's documented in the first visit notes. You get 1 data point for obtaining the old records and 2 data points for reviewing and summarizing them in your documentation. That's a total of 3 data points. If you order labs or Xrays you're up to 4 data points which means that depending on problem points and risk you may have a high complexity MDM.

Hope that helps.

F Tessa Bartels, CPC, CEMC