Evaluation and Management

What Should Be Provided if Medical Records Are Requested for Review?

The following should be considered if applicable to the service being reviewed. This is not intended to be an all-inclusive list.

  • Progress/visit notes
  • Physician orders
  • Medication records
  • Diagnostic test results (radiological studies, laboratory reports)
  • History and physical
  • Treatment plan if applicable
  • Procedure reports

The information could also include previous dates of service that support the need for the date of service being requested.

Posted 9/30/2024