Go Back   AAPC Medical Coding & Billing Forums > Medical Coding > E/M
Forum Rules FAQ Members List Calendar Search Today's Posts Mark Forums Read

Reply
 
Thread Tools
  #1  
Old 05-26-2011, 01:13 PM
bwilcoxen bwilcoxen is offline
New
 
Join Date: Apr 2007
Location: Springfield, IL
Posts: 2
bwilcoxen is on a distinguished road
Default Discussion of case with another provider-MDM



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
Reply With Quote
  #2  
Old 05-26-2011, 09:35 PM
dadhich.girish dadhich.girish is offline
Guru
 
Join Date: Apr 2007
Location: New Delhi, India
Posts: 202
dadhich.girish is on a distinguished road
Post

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.
__________________
Girish Dadhich, CPC
Reply With Quote
  #3  
Old 05-27-2011, 10:12 AM
FTessaBartels FTessaBartels is offline
True Blue
 
Join Date: Apr 2007
Location: Milwaukee WI
Posts: 4,436
FTessaBartels will become famous soon enough
Default I would count it

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
Reply With Quote
  #4  
Old 06-03-2011, 11:32 AM
lfreemanbaker lfreemanbaker is offline
New
 
Join Date: Apr 2007
Posts: 6
lfreemanbaker is on a distinguished road
Default Good question...

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.
Reply With Quote
  #5  
Old 06-06-2011, 10:23 AM
bwilcoxen bwilcoxen is offline
New
 
Join Date: Apr 2007
Location: Springfield, IL
Posts: 2
bwilcoxen is on a distinguished road
Default thank you

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

Thread Tools

Posting Rules
You may not post new threads
You may not post replies
You may not post attachments
You may not edit your posts

BB code is On
Smilies are On
[IMG] code is On
HTML code is Off




Disclaimer: Although AAPC staff members will monitor these forums periodically, we cannot be responsible for the information posted herein, nor guarantee its accuracy. Our members may discuss various subjects related to medical coding, but none of the information should replace the independent judgment of a physician for any given health issue. Please note that the opinions expressed here do not necessarily reflect those of AAPC.

All times are GMT -6. The time now is 11:31 PM.

AAPC - Top

Powered by vBulletin® Version 3.8.1
Copyright ©2000 - 2014, Jelsoft Enterprises Ltd.
Copyright ©2014, AAPC