decisionhealth Newsletters, Coder Pink Sheets - 2007 Issue 1 (January)
Use these strategies for billing medical records reviews
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Article Overview
This article covers billing considerations for medical records review in the context of E/M services, including how patient presence and counseling time affect whether the work may be counted. It also notes a distinction between paper chart review and certain electronic data-related codes, making it relevant to coders, billers, and clinicians who document review time.
Why This Topic Matters
Understanding when records review is bundled into an E/M service versus when it is not helps avoid unsupported billing and improves documentation accuracy. The article also helps readers distinguish chart review from other data-review services that use different CPT codes.
What You Will Learn
- When medical records review may be included in an E/M service
- Why patient presence matters for billing chart review time
- How electronic data review is treated differently from paper records review
- Which CPT data-review codes are mentioned as distinct from records review
Who Should Read This
- Medical coders
- Medical billers
- Physicians
- Practice administrators
- Clinical documentation staff
Codes Discussed
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