Discussion of case with another provider-MDM

[bwilcoxen]

I am hoping I can get assistance with this please. I am having a debate regarding what needs to be documented to count the 2 points for "discussion of case with another healthcare provider" in MDM. External auditors are stating "D/W onc fellow, Dr X, will give dose of IV ceftriaxone now and I will call with CXR results to determine final dispo." is not enough to count but were unable to give me what they'd like to see in order to count this.

Any input is appreciated and thank you

[dadhich.girish]

Documentation is a bit confusing itself. If the provider has D/W Dr. X and then given IV ceftriaxone, then it should be considered. Hope this helps.

[FTessaBartels]

I would give credit when the provider stated he discusssed the case with Dr X.
Perhaps he could further support this by stating a cause/effect.

Example: Discussed with Dr X of oncology service and he suggests we give dose of IV ceftriaxone now and I will call him with CXR results to determine additional treatment or transfer of care.

Hope that helps.

F Tessa Bartels, CPC, CEMC

[terca60647]

This has been the source of debate, especially since the guidance for such is vague at best.
However, reasoning on E/M guidelines seems to suggest that simply stating D/W is not seem sufficient. E/M guidelines usually asks for a brief description of discussion and the results of that discussion when using these discussions to determine E/M levels. As always in documentation, a brief synopsis of what is discussed would fix this.

For instance stating "D/W Dr. X that the patients insulin level does not seem to be stabilizing. Dr. X mentioned that [xxx] seems to be the problem and suggests increasing the patient's [xxx] and ordering [xxx] labs". I will increase the medication and call Dr. X back with lab results.

[bwilcoxen]

Thanks for all the responses, I certainly appreciate the feedback.
Brenda