tci General Surgery Coding Alert - 2003 Issue 10

Reader Question: Include Chart Review in E/M

Question: A patient had her past medical records, containing more than 10 years of history, sent to our general surgeon for review. Not all of the history related to her current condition. How can I charge for the doctor's time reviewing these records?Nebraska Subscriber 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 time component described in the E/M codes, "the pre- and post-face-to-face work associated with an encounter was included in calculating the total...

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