Outpatient Facility Coding Alert - 2015 Issue 2
Reader Question: Expect Record Review to Be Part of Office Visit
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Article Overview
This reader Q&A addresses whether physician time spent reviewing a patient’s records can be billed separately or reflected within an evaluation and management visit. It discusses CPT prolonged services without direct patient contact, documentation expectations, payer differences, and how record review may affect the data portion of medical decision-making for office/outpatient E/M services. The article is relevant to coders, billers, and physicians who document and select E/M services.
Why This Topic Matters
Record review is a common part of office-based care, but payment and coding treatment can differ by payer. Understanding where the work may be separately reportable versus folded into E/M selection helps avoid missed reimbursement opportunities and compliance problems.
What You Will Learn
- How record-review time may relate to prolonged services and office/outpatient E/M coding
- Why payer policy affects whether separate payment is available
- How documentation of record review can influence medical decision-making
- How data review may affect selection of an established patient office visit level
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Practice managers
- E/M auditors
Codes Discussed
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