tci Part B Insider - 2014 Issue 19

Reader Question: Historical Review May Not Be Billable

Question: A patient had her past medical records, containing more than 10 years of history, sent to our doctor for review. Not all of the history related to our specialist. How can I charge for the doctor’s time reviewing these records? Answer: CPT® considers reviewing records as integral to the E/M service, and you should not bill for it separately. Although CPT® does not include the time associated with records review in the E/M code descriptors, “the pre- and post-face-to-face work associated with an encounter was included in calculating the total work of typical services in physician...

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