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Ob-Gyn Coding Alert

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 ob-gyn for review. Not all of the history related to ob-gyn. 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 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 surveys." Consequently, the service described by the E/M codes "is a valid proxy for the total work done before, during, and after the visit," CPT states.
On the other hand, if your ob-gyn reviews the records and writes a summary of those records, you may be able to raise the level of medical decision-making (MDM) - this applies to the elements of tests ordered or reviewed - which may allow you to choose a higher-level E/M service when combined with the history and examination. Medicare gives two points for summarizing medical history. For instance, if your physician also orders and reviews a lab result or an ultrasound, then the data category for MDM increases to multiple. If risk to the patient is moderate, this would lead to moderate-complexity MDM. When combined with a detailed history and examination, you have a level-three new patient service (99203) or a level-four established patient service (99214).