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2 Points for Review and Summarization of Records

K

KaylaRieken

True Blue
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527
Location
Waukee, IA
When we see new patients we often receive referral records that our urologists review. Is it ok to give them the 2 points for reviewing the records when they are dictating a summarization of what they are reading?
 
Check your payers policy on E/M documentation. CMS doesn't specify a point system in the MDM (I know AAPC uses it though), and many auditors like to have the MDM quantified; however at the end of the day the whole E/M visit boils down to Medical Necessity instead of fulfilling documentation requirements.

All that said, if documentation supports the "Review of medical records" + a good summary, then as an auditor I would probably accept the 2 points (can't do the other "Review of medical records" 1 point tho) towards Amount of Data in the MDM section.

CMS is also doing an overhaul of E/M requirements already for 2019, and more so for 2021. Read more about that in this Provider Letter from CMS. I also have a whole thread dedicated to the CMS E/M changes (might have to flip a few pages in the E/M group).


Hope this is helpful.
 
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