When and How Can You Bill for Chart Review?

Chart review in healthcare involves systematically examining a patient’s medical records to gather information about their past and active medical history, including lab results, immunizations, and treatments. This process provides healthcare practitioners with an overview of a patient’s condition, assisting in diagnosis, treatment, and prevention of medical issues. Medical chart reviews are also used for various purposes beyond direct patient care, such as validating insurance claims, supporting legal cases, and conducting research. The ability to bill for this activity, however, is not straightforward and depends on specific circumstances and its integration into other billable services.

When Chart Review is Billable

Chart review, while essential for patient care, is generally not a stand-alone billable service. Instead, time and effort spent reviewing medical records contribute to the complexity and level of other billable services. This integration allows chart review to be recognized for reimbursement.

For Evaluation and Management (E/M) services (e.g., new or established patient visits, consultations), chart review significantly influences medical decision-making. Reviewing records adds to data complexity, helping determine the appropriate E/M level. Thorough chart review can justify a higher E/M service level, reflecting increased cognitive effort.

Prolonged services allow for chart review time, especially when it directly contributes to patient care beyond the typical time for the primary E/M service. This non-face-to-face time, even on a different date than the primary service, can be reported if it relates to ongoing patient management. For instance, extensive record review may be necessary after receiving past records related to a previous E/M service.

Critical care services include extensive chart review for managing critically ill patients. Critical care involves continuous assessment and management, integrating historical data review into the overall service. Similarly, in care management services like Chronic Care Management (CCM) and Principal Care Management (PCM), chart review is a billable part of ongoing care coordination and management. These services recognize the ongoing work in managing a patient’s conditions, including regular review of their medical information.

Chart review can be recognized as part of other billable services, such as diagnostic test interpretation. When a healthcare professional interprets a diagnostic test, reviewing relevant patient history and prior test results from the medical chart is integral to forming an accurate interpretation and report. This integrated activity supports the billable service of test interpretation.

When Chart Review is Not Separately Billable

While chart review is often necessary for healthcare delivery, it cannot be billed as a distinct service in specific scenarios. Routine chart preparation before an encounter, for example, is generally considered part of overhead for providing healthcare services. This includes reviewing basic patient demographics or routine updates that do not significantly alter medical decision-making for the upcoming visit.

Chart review for internal quality improvement or compliance audits is not separately billable. These activities, while important for maintaining high standards of care and regulatory adherence, are administrative functions of the healthcare organization. Similarly, reviewing records for research, unless explicitly tied to a billable clinical trial or service, falls outside direct patient care billing.

Administrative tasks related to chart review, such as preparing for peer review or legal cases not directly linked to a billable patient care encounter, are not reimbursable. These tasks support a practice’s operational aspects rather than providing direct patient care that qualifies for billing. Reviewing records for services already rendered and previously billed also falls into this category, as the work has already been accounted for.

The distinction lies in whether chart review directly contributes to a billable patient care service and influences medical decision-making, or if it serves an administrative, preparatory, or quality assurance purpose. If the review does not directly inform or contribute to a billable clinical encounter, it is considered part of a healthcare practice’s operating costs.

Essential Documentation for Chart Review

Accurate documentation is necessary when chart review contributes to a billable service. The medical record must reflect the reason for the chart review, providing a rationale for the time and effort expended. This includes detailing why specific past medical history, lab results, specialist reports, or prior treatments were reviewed for the current encounter or care plan.

Specific findings from the chart review that influenced medical decision-making or patient management must be recorded. This means noting how the information reviewed led to a particular diagnosis, treatment plan, or modification of an existing plan. Simply stating a chart was reviewed is insufficient; documentation must demonstrate the clinical relevance and impact of the review.

For time-based services (e.g., prolonged services or E/M services where time is the controlling factor), the exact time spent on chart review must be accurately documented. This time should be clearly associated with the patient’s care on the day of the encounter or directly related to ongoing patient management. Documentation should also identify the person who performed the chart review, ensuring accountability and proper attribution.

This documentation serves as evidence to support the medical necessity and complexity of the service provided. It allows for justification of the selected E/M level or billing of prolonged services, ensuring compliance with coding and billing regulations. Without comprehensive documentation, even legitimate chart review efforts may not be reimbursable.

Coding and Billing Considerations

Translating documented chart review into billable claims requires understanding specific coding principles and guidelines. Chart review directly influences the correct Evaluation and Management (E/M) level for a patient encounter. The complexity of data review, including old medical records, is a component in determining the overall medical decision-making complexity for an E/M service. This data review contributes to the total points needed to achieve a specific level of medical decision-making, supporting a higher E/M code (e.g., 99202-99499).

For prolonged services, specific CPT codes can be used when chart review time extends beyond the typical time for a primary E/M service. While some prolonged service codes (e.g., 99354-99357) relate to face-to-face time, others (e.g., 99417 or HCPCS add-on code G2212) are used for non-face-to-face prolonged E/M services when time is the basis for code selection. These codes allow capture of extensive chart review that is medically necessary and contributes substantially to patient care.

When a separate, significant E/M service is performed on the same day as a procedure, Modifier 25 might be appropriate. This modifier indicates the E/M service, which could include substantial chart review, was distinct from the procedure. It is important to consult official coding guidelines (e.g., CPT and CMS) for detailed rules on applying modifiers and selecting codes.

The principle for billing chart review, as with all healthcare services, is medical necessity. Chart review must be clinically relevant and necessary for the patient’s diagnosis or treatment. Accurate representation of services is also important, meaning chosen codes must precisely reflect the work performed and documented. Adherence to these guidelines ensures proper reimbursement and avoids potential compliance issues.