ER E/M physician documentation

lsolway

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Paso Robles, CA
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I review ER charts for both facility and professional leveling. If a physician ordered a diagnostic test (any- lab, CXR, EKG and/or IV) and the results are in the patient's record, but he does not mention of one or more of these in his documentation, can this still be used in the MDM? Or am I to strictly go off his documentation? Also for PMFSH, a lot of physicians write- "see nurses notes" or "unknown if ever smoked" or "never smoker or drug use" (for a child sometimes). Not sure how to count this. Any suggestions on training or education for ER E/M leveling? Thanks
 
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jimbo1231

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Brooklyn, New York
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The data guideline is review or order. So f there is some documentation of order, that should be OK for 1 point. As to Social History, with an adult or even teenager, no history smoking or drug use is adequate for SH. For a 6 year old that is questionable. Usually for kids there is at least something about attending school or living with parents documented. As to "See Nurse Notes" I'd be looking for something a little more specific like "Review and concur with Nurse Notes, with following addition...." along that line to document that there provider actually looked. Jim S.
 

jvanbk

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Local Chapter Officer
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Bonita Springs, Florida
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As long as the physician's intention to order the tests are within his E/M note, you can use that test for Amount and Complexity of Data for the E/M. You need either the order, intention to order, or the results within the provider's note.
 
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