1.9 Reports

Any bill received from a medical service provider must include the service provider’s written report. Preparation of this report is considered part of the authorized service and does not warrant additional fees. This provision also applies to required periodic progress reports for services, which extend over a period of time, such as physical therapy, psychotherapy, etc.

The report must include, at a minimum:

• Patient's diagnosis (periodic progress reports do not need to repeat the diagnosis);

• Description of the service(s) provided;

• Treatment procedures;

• Outcome of treatment;

• Identification of type of provider and credentials: If information has been gathered or synthesized by someone other than a Doctor of Medicine or a doctor of osteopathy, it is only acceptable when the actual report indicates through co-signature that it was prepared under the supervision of one of the above; and,

• Date(s) of service(s) provided.

Additional Report Requirements for Office Visits, CPT codes 99201-99220:

• Summary of pertinent medical history;

• Scope of examination; and

• Complexity of medical decision making which is consistent with the descriptions of office visits.

Additional Report Requirements for Specialized Disability Assessments, CPT codes 99455 or 99456:

• Summary of pertinent medical history;

• Results of a sufficiently comprehensive physical examination;

• Diagnosis;

• Summary of capabilities;

• Level of stability;

• Functional limitations; and

• Proposed treatment, if any.

Reports for physical medicine procedures (physical therapists and occupational therapists) must contain sufficient information to justify a CPT 97000-series office visit.

Reports accompanying unique procedures without relative values must also reflect the complexity of the procedure and the length of time required to complete the procedure.

(Procedure codes 01999-01, 01999-02, 01999-03, 01999-04, 01999-05, 01999-06, 01999-07)

Reports should include the provider's supplemental report, progress notes (other than required progress reports), or office notes, and should only be paid for when the counselor specifically requested them. For special narrative reports, the content should be established with the provider before the report is prepared.