Wiki Documents reviewed during encounter

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ksanthony

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If the provider reviewed documents in preparation for the patients visit such as CT Scans, MRI's, ER reports and it is documented in the encounter summary that these documents were discussed with the patient would these not count as Data reviewed to support MDM? There is a debate with a coder stating it cannot be counted because it is mentioned in the HPI...which is actually not correct. Do we have double dipping in 2023?
 
I'm a bit confused about what argument is being made against counting the review toward data. Did the provider order these tests at the previous visit and is now reviewing them at a follow-up? If so, the credit for the order and review counts toward only one point of data at the encounter the test is ordered.

Per E/M Guidelines:
Analyzed: The process of using the data as part of the MDM. The data element itself may not be subject to analysis (eg, glucose), but it is instead included in the thought processes for diagnosis, evaluation, or treatment. Tests ordered are presumed to be analyzed when the results are reported. Therefore, when they are ordered during an encounter, they are counted in that encounter. Tests that are ordered outside of an encounter may be counted in the encounter in which they are analyzed.
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The amount and/or complexity of data to be reviewed and analyzed. These data include medical records, tests, and/or other information that must be obtained, ordered, reviewed, and analyzed for the encounter. This includes information obtained from multiple sources or interprofessional communications that are not reported separately and interpretation of tests that are not reported separately. Ordering a test is included in the category of test result(s) and the review of the test result is part of the encounter and not a subsequent encounter.
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Sorry for the confusion. Yes, I understand the timing of when the test are ordered and to what encounter they can be counted towards. The issue here is that the coder is stating that review of the MRI is documented in the HPI and will not count towards data points for MDM and is therefor considering this a lower level visit. I guess my question is does this have to be documented in a particular place? Each EMR is different, some providers still use paper charts, as long as the provider indicates which document is reviewed / discussed as a part of this encounter would it not be counted towards MDM, ensuring it met the above reference guidelines.
 
ksanthony said:
Sorry for the confusion. Yes, I understand the timing of when the test are ordered and to what encounter they can be counted towards. The issue here is that the coder is stating that review of the MRI is documented in the HPI and will not count towards data points for MDM and is therefor considering this a lower level visit. I guess my question is does this have to be documented in a particular place? Each EMR is different, some providers still use paper charts, as long as the provider indicates which document is reviewed / discussed as a part of this encounter would it not be counted towards MDM, ensuring it met the above reference guidelines.
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As long as there is supporting documentation I don't see why credit cannot be given just because of what section of the note the review is documented in. I don't see how it counts for double dipping either. If the other coder feels strongly about this, perhaps you can ask them what guideline(s) they are referring to that disallows review of tests documented in certain parts of the note.
 
It doesn't matter where it "lives" in the note. Not every note conforms to a certain format. The documentation could be "backwards" to what we are used to seeing and it would still count. They could put the assessment and plan first, the HPI on page three and the exam on page two (example). Is the documentation present and has the elements required to report the particular code/level? If yes, it is not an issue. Sounds like your coder needs some education on documentation requirements. I agree with the advice above, let the coder show you the guideline or other backing documentation for this position.
If the provider reviewed outside notes that counts toward data. If coding by time the review of tests, etc. in preparation to see the patient is counted. This is with the exceptions mentioned above regarding ordering and review in the same encounter, etc.
 
Thank you both for your input, I concur. Yes, the coding team working these claims needs a refresher on several issues. :)
 
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