Part B Insider - 2014 Issue 7
Reader Question: Record Review Can Impact MDM
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Article Overview
This reader question and answer addresses whether a surgeon’s time spent reviewing extensive prior medical records can be reported separately or reflected within an E/M service. It also discusses how records review may influence medical decision-making documentation and why payer policy matters. The article is useful for coders, billers, and physician practices that need to understand time-based reporting and documentation support for E/M-related services.
Why This Topic Matters
Record review is common in specialty care, but payment treatment varies by payer and by how the work is documented. Understanding the scope of allowable reporting can affect compliant billing and E/M level selection.
Article Sections
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Question
A reader asks whether extensive review of prior medical records by a surgeon can be billed and under what circumstances the work may be recognized.
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Answer
The response discusses general reporting considerations for non-face-to-face record review, the importance of documentation, payer variability, and how record review may affect E/M service selection through medical decision-making.
What You Will Learn
- How prior-record review may relate to professional service reporting
- Why documentation of time and work performed matters
- How payer policies can affect recognition of non-face-to-face services
- How record review may contribute to medical decision-making in E/M selection
Who Should Read This
- Medical coders
- Billing staff
- Physician practices
- Surgeons
- Compliance staff
Codes Discussed
Code Ranges Discussed
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