Wiki 1995 E/Mguidelines - Discussion with another healthcare provider

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RABBIT2020

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Hello All,

Based on the audit tool would you say if it would be appropriate to consider 2 points for a discussion in the scenario I have presented.
Should you have any supporting guidance for this please also include in your response.

The attending MD sees the patient and determines in his plan that the patient needs a consult with Cardiology (or any specialist). The specialist sees the patient as requested after which the specialist documents his/her
report with recommendations and upload it on the same EMR as the attending MD. All this is happening on the same day at the same facility.
The attending MD reads the specialist report and the recommendations and updates his note to state: 'As per Cardio patient is ok to discharge. Perform ekg. Stay on current meds"

Would this statement on the attending MD note qualify for 2 points?
Table 3b audit tool 2017 for 1995 guideline:
Review and summarization of old records and /or history from someone other than patient and/or discussion of case with another health care provider
 
1
No, I would not give 2 points. Reading a cardio note is not the same as discussing the patient with another physician and these is also not history being obtained from someone other than the patient or old notes being reviewed. Usually, when the attending discusses the case with another physician it is because it is a complex case requiring verbal discussion on how best to treat the patient (thus the 2 points given for complexity) .
 
0
I agree with the above. Because the two physicians did not actually speak with one another to work out a treatment plan for the patient, I wouldn't give two points.
 
1
No it would not in my opinion. What you describe is not any of those three items. Simply reading the consulting physician's report is not discussion. See: https://www.cms.gov/outreach-and-ed...n/mlnedwebguide/downloads/95docguidelines.pdf "DG: The results of discussion of laboratory, radiology or other diagnostic tests with the physician who performed or interpreted the study should be documented."

Even though this definition is located in the updated office/other oupatient guidelines, it defines what the meaning of discussion is which, in my opinion, you can use for guidance as well. Discussion: Discussion requires an interactive exchange. The exchange must be direct and not through intermediaries (eg, clinical staff or trainees). Sending chart notes or written exchanges that are within progress notes does not qualify as an interactive exchange. The discussion does not need to be on the date of the encounter, but it is counted only once and only when it is used in the decision making of the encounter. It may be asynchronous (ie, does not need to be in person), but it must be initiated and completed within a short time period (eg, within a day or two).
 
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