Data points for MDM

ngou719

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Can anyone help me with examples for the data points area of MDM. My client would like to know what could be considered other than what is listed on the E/M auditor instruction sheet. They tend not to do anything in radiology or talk with other providers, or request documentation from the outside. Also,if a provider reviews a lab and then ordered another could that be listed as 2 points? Any suggestions are greatly appreciated!
 
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jlg1507

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Local Chapter Officer
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The auditing tool states 'Clinical lab ordered AND/OR reviewed - -therefore it cannot be counted as 2 points. Same goes for Radiology and Medical testing. If the provider contacts another provider to discuss the patient's condition or to obtain advice (even within the same practice), this would fall under obtaining information from someone other than the patient and count as 2 points. Be sure to count Review/Summarizing old records when the provider has taken the time to go back through the chart and documented test results over a period of time or gives a summary of past treatments, etc. This information couldn't be documented if they didn't take the time to review the record - so it counts. Be sure to counsel your providers to document - -sometimes they short change themselves by not recording all they do. If they look at imaging themselves to view an x-ray, CT, MRI, etc. (or a tracing specimen) - not just the printed report - they must document that they did this so they get credit for the work. Review of the report is 1 point and direct visualization of the image is 2 points giving 3 points for DATA which can make a real difference when figuring MDM.
 

thelton

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I would be careful giving a point for reviewing a report and 2 points for reviewing the images for the same study. Our MAC stated in a webinar that is is an either/or situation, not both.
 
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