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How to Bill for Report of Findings Visits

Billing for Report of Findings Visits

Have you been wondering how to bill for Report of Findings visits? Since there is no official "Report of Findings" billing code here is more information on how you can still get paid for those services.

Use Counseling Time Override for Report of Findings Visits

Counseling/Coordination of Care is a discussion with the patient and/or family concerning one or more of the following areas:

  • Diagnostic results, impressions, and/or recommended diagnostic studies

  • Prognosis

  • Risks and benefits of management (treatment) options

  • Instructions for treatment and/or follow up

  • Importance of compliance with chosen treatment options

  • Risk factor reduction

  • Patient and family education

Remember these important steps:

  • Counseling/Coordination of Care and its associated time must be identified and documented.

  • In Document Plus, generate the Patient Report of Findings and use it as a guideline for your counseling/ coordination of care session.

  • On the report, document the beginning and end times along with the doctor's signature.

  • Use the Document Plus Image Center to scan the signed report back into the patient file.

  • Bill the appropriate established patient E&M code (with a modifier -25 if treatment was also performed that day).

If you have any questions about these procedures please feel free to give us a call.

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