Wiki MDM data points question

[reddaway@sbcglobal.net]

can "reviewed patient's past psychiatric history prior to seeing the patient" count as review and summarization of old records for 2 points in the data points section in MDM? or is there more documentation required to meet the definition of summarization?

We have a new provider who is taking over care of patients for a provider who has left our facility and he is reviewing history information prior to seeing each patient but is only dictating the above sentence.

Thanks for any insight you have.

 

[Pathos]

The MDM portion of any E/M visit is often the most subjective part of the E/M visit, and can be tricky to decode/translate into points.

When you state if the above example is enough to count 2 points towards the "Review and summarization of old records", in my mind there should be more documentation to support the 2 points. If I was auditing that chart (and I would have to see the rest of the chart to cement my opinion), I would most likely NOT attribute the desired 2 points based on "Review and summarization of old records", because I do not see a summarization at all. An example of a summarization could be: "Reviewed patient's past psychiatric history prior to seeing the patient. Took particular note of the patient's struggle of their bipolar condition and medication noncompliance, and plan to revisit this concern with the patient." or something that would reveal information pulled from the psych record. The summary doesn't have to be as long as my example, but should include additional information besides the original sentence above.

CMS E/M guidelines:
https://www.cms.gov/Outreach-and-Ed.../Downloads/eval-mgmt-serv-guide-ICN006764.pdf

Hope this is helpful!

 

[reddaway@sbcglobal.net]

Very helpful. Thank you!