Outpatient Facility Coding Alert - 2014 Issue 19
Reader Question: Historical Review May Not Be Billable
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Article Overview
This article answers a coding question about whether a physician’s review of long-standing medical records can be billed separately. It discusses CPT evaluation and management guidance, the relationship between pre- and post-visit work and E/M services, and how record review documentation may factor into medical decision-making for office visit selection. The piece is relevant to coders, billers, and physicians working with E/M documentation and history review.
Why This Topic Matters
Record review is a common part of specialty care, and misunderstanding its billing status can affect code selection and documentation support for office and other evaluation and management services.
What You Will Learn
- How record review is treated in relation to evaluation and management services
- How documentation of reviewed history may relate to medical decision-making
- How additional data review can influence the level of an office visit
- Why this topic matters for E/M documentation and coding
Who Should Read This
- Medical coders
- Billing staff
- Physicians
- Practice managers
- Compliance staff
Codes Discussed
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