Wiki MDM - Amount and/or complexity of data when scoring MDM


Claysville, PA
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I have always thought that in order to count a lab or test result, the doctor must state that he/she reviewed the labs or tests results and state the results or "render an opinion". He cannot just say "I reviewed the lab results". Can anyone clarify this for me?
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As far as "scoring" goes, it does not matter if the physician reviews one lab or twenty, he gets the one point either way. However, you have a documentation concern. The physician needs to state if the labs are normal or within normal limits or not. Or the physician could state that all labs were normal and state any that were elevated or low. This could make a difference in other areas of MDM. Like, is the patient responding to treatment? If all the labs are WNL, probably yes. If not, maybe not. If the physician was being audited, an auditor may not give the physician credit just for simply stating that labs were reviewed without stating if they were within normal limits, elevated or low. Seems like a simple thing, but there is more to it than most physicians realize from a compliance point of view.