Wiki MDM Question

[CindyWeems]

When your provider reviews hospital records for a hospital follow up visit, can pull out the lab and x-rays done in the hospital and count those separately for your amount of complexity? Example: review and summarization of old records are worth 2 points and then the x-ray and lab work done during the hospital stay is worth 1 point each. Is that allowed?

 

[smoore123]

Hi Cindy,

If I am understanding this correctly the provider reviewed labs and x-rays, total 2 points. Its hard to give you an accurate answer without reviewing the documentation. Did he personally review and summarize the x-rays and review labs if so that would be 1 point for the lab(s) and 2 for him PERSONALLY reviewing a summarizing the x-ray.

 

[CindyWeems]

Here is the record. Would you give it 2 points (reviewing hosp. records) or 4 points (reviewing hosp records & labs & x-ray)? THANKS

Review & summation of old records: Patient was seen inpatient for extremely shortness of breath. Chest CT showed multilobar pneumonia
and Iv antibiotics was started. Pt. blood count remained high and blood culture came back MRSA. Pt. was concerned for endocarditis and tranthoracic echo was done which were negative, then transesophagel echocardiogram were done which show some vegetations on aortic valve. was treated with antibiotics and improved and was discharged to rehab.

Review clinical lab tests(cbc): wbc 16.6
Review radiology test(xray,ct): CT chest showed multilobar pneumonnia.

 

[smoore123]

2 points.