Question Data Points in the Medicine Section Reviewed/Order

CHARLENA79

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I have always given providers credit under data/medicine section for referring/ordering physical therapy and referring the patient to another specialty such as neurosurgery/orthopedics. Am I interpreting the guideline accurately?
 

thomas7331

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My understanding is that the data section is only for the order and/or review diagnostic tests and other medical records. In the 1995 guidelines, referrals to specialists are addressed in the 'number of diagnoses or management options' section so would be counted, for example, as additional work-up required in the points of that section. Orders for physical therapy are a treatment option, so I would look to the risk section under 'management option' to credit that toward the MDM.

I think that is the traditional way that these would be audited but as always, keep in mind that MDM is probably the greyest of the grey areas, and these are guidelines, not hard and fast rules as to how MDM should be assessed.
 
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