Wiki CT pasted into the encounter note (MDM)

[Sarah Ann]

We have a provider that pastes the rad. report into the MDM- and that is it to me it's not their MDM- THEN there is no final diagnosis- just the report. I don't think we should report the findings from the report. The provider documenting the(professional) E/M should render a final diagnosis- is this correct?- Not the radiologist's findings.

 

[thomas7331]

I agree, if you are coding the E/M service, you would code only the diagnoses documented by the provider who performed that service. If the provider hasn't told you that they agree with those results, then I wouldn't code them.

When outside results are pasted into a note with no other commentary by the physician performing the current services, I will usually take it to mean that the provider has reviewed those results (for a data point, if applicable), but it tells me nothing more than that.

 

[jkyles]

We have a provider that pastes the rad. report into the MDM- and that is it to me it's not their MDM- THEN there is no final diagnosis- just the report. I don't think we should report the findings from the report. The provider documenting the(professional) E/M should render a final diagnosis- is this correct?- Not the radiologist's findings.

Right, if the provider doesn't document their medical decision making related to the chart there's nothing you can do with it except tell them they need to provide detail.

The fact that it is in there doesn't tell you anything except they know how to use the paste function.