Forum - Questions & Answers

Oct 22nd, 2009 - graciejean

Example of review of old records

Can the following information be counted as 2 points for review and summarization of old records:
Prior Neurology records reviewed which include Dr. A diagnosis of JME (Juvenile Myoclonic Epilepsy) and EEG with 5 hz spike and wave.

This is encounter with pediatric neurologist.

What documentation would reflect the review and summarization of old records?

Oct 22nd, 2009 - Codapedia Editor 1,399 

Example of old records reviewed

The Guidelines say this:

Relevant findings from the review of old records, and/or the receipt of additional history from the family, caretaker or other sources should be documented. If there is no relevant information beyond that already obtained, that fact should be documented. A notation of "Old records reviewed" or "additional history obtained from family" without elaboration is insufficient.

It looks like the doctor has documented the bare minimum to have it counted for two points in the history. A little more detail wouldn't hurt!

Oct 22nd, 2009 - Codapedia Editor 1,399 

Example of records reviewed

Nancy reminds me: this is counted when part of an E/M service, and is relevant in selecting the MDM of a code.



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