MDM and Research consultation

[kratomic62]

I am coding for E&M for a Patient with Prostate Cancer. My provider reviewed a number of test as well as discussed Treatment options with our research team regarding a posible research study. Can I count her discussion with Research toward the MDM?

 

[csperoni]

I think you are asking if this meets data for category 3 "Discussion of management or test interpretation". If so, a lot of this depends on who is meant by "our research team."
Discussion of management or test interpretation with external physician/other qualified health care professional/appropriate source. Per the AMA 2021 guidelines:
External physician or other qualified health care professional: An external physician or other qualified health care professional who is not in the same group practice or is of a different specialty or subspecialty. This includes licensed professionals who are practicing independently. The individual may also be a facility or organizational provider such as from a hospital, nursing facility, or home health care agency.

So, if "our research team" is another physician of the same specialty in your same group practice, then no. If "our research team" means some type of administrative employee who manages paperwork and/or keeping track of which trials are open and the requirements, then no. If provider seeing patient is hem/onc and "our research team" means a surgical oncologist, then yes. As always, the note must include documentation of the discussion.

Hope that helps. If you were not asking if this meets "Discussion of management or test interpretation" then please clarify.