GOÄ 75B VI — Berichte, Briefe130 points

GOÄ Number 75: the detailed written illness and finding report

Fee

17,43 €130 points × 5,82873 Cent × 2,3

The point count stands as written in the Gebührenverzeichnis; the point value stands in § 5 Abs. 1 Satz 3 GOÄ. The amounts are computed from these and rounded to the cent, as § 5 Abs. 1 Satz 4 requires. Which multiplier is appropriate in an individual case is set by § 5 Abs. 2 according to difficulty, time taken and the circumstances of performance — the practice decides that, not this table.

Service text

„Ausführlicher schriftlicher Krankheits- und Befundbericht (einschließlich Angaben zur Anamnese, zu dem(n) Befund(en), zur epikritischen Bewertung und gegebenenfalls zur Therapie)“

Not alongside — per the Gebührenverzeichnis (1)

Numbers the fee schedule names together with this one in an exclusion sentence. Open a chip for the wording, in German, and where it stands; about a particular case the sentence says only what it says.

Number 75 is valued at 130 points: the detailed written illness and finding report, which includes the history taken from the patient, the finding or findings, the overall written assessment of them, and, where applicable, the therapy. That gives 7,58 € at the single rate and 17,43 € at the 2.3-fold rate. What matters most is the line to a mere communication of a finding: a communication, or a simple finding report, is already covered by the fee for the underlying service and is not separately billable alongside it. What draws that line is the extent of the written work, not the mere passing on of a result.

The service text of Number 75

The service text lists four elements, and all four belong to the same report: what the patient reported, what was found, how the two are brought together and assessed, and — where it comes to that — what therapy follows from it. None of the four elements carries the number on its own.

The boundary is drawn by a separate provision, not by the service text itself: a communication of a finding — merely passing on a result — or a simple finding report is already covered by the fee for the underlying service. Only a report that goes beyond such a communication satisfies the service text of Number 75.

What decides that difference in a given case is the extent of the written work: whether the history and the finding are brought together and assessed, or whether only a result is passed on. The ordinance itself does not draw this line by a word count, but by what the report actually does.

The sentences below stand exactly like this in the Gebührenverzeichnis — one directly under Number 75, the others as Allgemeine Bestimmungen shared with other numbers. They are quoted here in German, word for word rather than summarized, because the sentence that draws the line to a mere communication is exactly the sentence that matters, and a paraphrase of it would be a claim of its own. The English text after each dash is a working translation, not a substitute for the statutory wording.

„Die Befundmitteilung oder der einfache Befundbericht ist mit der Gebühr für die zugrundeliegende Leistung abgegolten.“ — The communication of a finding, or the simple finding report, is covered by the fee for the underlying service.
„Neben der Leistung nach Nummer 435 sind für die Dauer der stationären intensivmedizinischen Überwachung und Behandlung Leistungen nach den Abschnitten C III und M sowie die Leistungen nach den Nummern 1 bis 56, 61 bis 96, 200 bis 211, 247, 250 bis 268, 270 bis 286a, 288 bis 298, 401 bis 424, 427 bis 433, 483 bis 485, 488 bis 490, 500, 501, 505, 600 bis 609, 634 bis 648, 650 bis 657, 659 bis 661, 665 bis 672, 1529 bis 1532, 1728 bis 1733 und 3055 nicht berechnungsfähig. Diese Leistungen dürfen auch nicht anstelle der Leistung nach Nummer 435 berechnet werden.“ — Alongside the service under Number 435, for the duration of inpatient intensive-care monitoring and treatment, services under Abschnitte C III and M and the services under Numbers 1 to 56, 61 to 96, 200 to 211, 247, 250 to 268, 270 to 286a, 288 to 298, 401 to 424, 427 to 433, 483 to 485, 488 to 490, 500, 501, 505, 600 to 609, 634 to 648, 650 to 657, 659 to 661, 665 to 672, 1529 to 1532, 1728 to 1733 and 3055 are not billable. Nor may these services be billed in place of the service under Number 435.
„Als Behandlungsfall gilt für die Behandlung derselben Erkrankung der Zeitraum eines Monats nach der jeweils ersten Inanspruchnahme des Arztes.“ — For treatment of the same illness, the treatment case is the period of one month after the patient's first attendance.
„Terminvereinbarungen sind nicht berechnungsfähig.“ — Arranging an appointment is not billable.

The multiplier for Number 75

Number 75 stands in Abschnitt B, so it falls within the ordinary fee range: from the single rate up to the 3.5-fold rate, with the 2.3-fold rate as the span within which, under § 5 Abs. 2 Satz 4 GOÄ, a fee is as a rule assessed.

§ 5 Abs. 2 Satz 1 GOÄ names the criteria that fee is measured against: the difficulty and the time taken for the particular service, and the circumstances of how it was performed; criteria already accounted for in the service text — such as that a report covers the history, the finding, the assessment and, where applicable, the therapy — are left out of consideration under Satz 3.

Above the 2.3-fold rate, § 12 Abs. 3 GOÄ requires a written justification tied to the particular service, comprehensible and traceable for the person liable to pay. For a report whose effort lies precisely in its thoroughness, that thoroughness itself is the starting point for such a justification — not the underlying finding, but the written work done on it.

What the record has to carry for Number 75

The treatment record is independent of the fee schedule — § 630f BGB requires it in immediate temporal connection with the treatment, whoever pays. For Number 75 that connects closely with the billing itself: the report is written from what was already recorded about the history and the finding.

Whether a report crosses the line from a mere communication can only be judged afterward if it stays visible what was actually brought together and assessed. That applies to billing under Number 75 just as it does to a later question from the person liable to pay under § 12 Abs. 3.

A justification above the 2.3-fold rate can only be drawn from a record that carries more than the result: the time, the extent of what was recorded, the assessment. A conversation documented while the treatment itself is happening supplies exactly that starting point for the later report — whatever means the record is made with.

Frequently asked questions

Is a communication of a finding the same as Number 75?

No. The provision states expressly that a communication of a finding, or a simple finding report, is covered by the fee for the underlying service; Number 75 applies only once a report goes beyond that.

What has the report under Number 75 got to contain?

The service text names four elements: the history, the finding or findings, the overall written assessment of them, and, where applicable, the therapy.

What does Number 75 cost at the 2.3-fold rate?

130 points times the point value of 5,82873 Cent give 7,58 € at the single rate; 2.3 times that is 17,43 €, and 3.5 times is 26,52 €. Rounding is to the cent, under § 5 Abs. 1 Satz 4 GOÄ.