Wiki counting discussion of case with other health care provider in reviewing level of MDM

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leeannatk

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I have generally required separate documentation of a discussion with other providers to give credit in this data area on chart review. I.E.: Discussed with Dr. Smith who agrees with plan to ....."
I have a group who has been documenting at the start of all notes "patient was discussed on multidisciplinary rounds" or something similar.
They feel they should get the 2 points "credit" as this is their discussion with other providers. I feel like it's a bit gray - and the patient may not always have other providers involved in their care but a reviewer would not be able to discern this by the note.

Anyone have an opinion on this?

Lee Ann, CPC, CHA
 
Specific physician and nature of discussion

I give credit only when the documentation cites a specific physician was consulted and the nature of that discussion. For example: I spoke with Dr Cardiologist about patient's needs in re upcoming surgery and hospitalization.

I would not give credit for a generic "case discussed on multidisciplinary rounds."

Hope that helps.

F Tessa Bartels, CPC, CEMC
 
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