Credit in MDM

MMadrigal

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Could someone familiar wtih auditing help me with correct documentation for "Reviewed previous chart notes" in MDM. It is normal for doctor to go take a look at the previous chart notes, when pt comes in. Are we allowed to get credit in MDM for this, and if so, how do we correctly document this? Also, doctor will sometimes note "previous x-ray or MRI reviewed". Do we get credit for this note? Thanks so much, Mary
 
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Read the full guidelines

It would be helpful to read the full guidelines

Under DATA points, the physician can get 2 points for:
Review and summarization of old reords and/or obtaining history from someone other than patient and/or discussion of case with another health care provider. (emphasis added by FTB)

That's 2 points TOTAL even if all three elements are performed. Please note the phrases/words I've emphasized. Just looking at the chart notes of the last visit wouldn't qualify - in my opinion.

On the other hand, if the documentation was something like: I obtained the records from XYZ and reviewed them, noting in particular that ABC treatment was only moderately effective. - I would probably give that credit.

As for the statement "previous Xray or MRI reviewed" ... I'd give 1 point for the "review and/or order of tests in the radiology section of CPT" If the documentation was more specific as to the physician actually looking at the images (vs possibly just looking at the radiologist's report), then I'd give 2 points.

Hope that helps.

F Tessa Bartels, CPC, CEMC
 

MMadrigal

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Thanks so much Tessa

I know for certain, when doc states he "reviewed previous x-rays, or MRI", he's pulling up on the computer and looking at the actual films.

When he documents "previous record reviewed", he's usually going back to the previous visit, refreshing his memory.

If these two actions qualify for additional credit, I don't was to miss them, because we don't know how to document them correctly.

I so appreciate your feedback. Mary
 

mdoyle53

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Looking at a previous patient record would not count towards MDM as this is part of the treatment plan. However, had it been several years since the patient was in and therefore there is no treatment plan in place and the MD goes through the old records and summarizes, then I would be more apt to give credit.

Reviewing the MRI/Xray - I would provide credit if this is the first time or it is important to review again (this is very subjective). Just looking at it for a subsequent time would not qualify unless there was some type of documentation as to why and the importance of the extra review/s.
 
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