Mdm

coder21

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Hi,
I have a question. I have a provider who saying she should get points in the amount of data for order and reviewing a ct and also points for independently visualization of an imagine when she read the CT scans and interrupts it in the chart. Is this double dipping and where can I find the information on this?

Thank you
 

coder21

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Thank you! Question would be this provider didn't order the CT she reviewed the one performed in the ED.

So her thought:

1 point for order/review of rad
2 points for independently visualization which she documents her finding

For a total of 3 points on the same CT?
 

Pathos

True Blue
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Beaverton OR
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CMS E/M guidelines say:

"The direct visualization and independent interpretation of an image, tracing, or
specimen previously or subsequently interpreted by another physician."


As long as the two images/studies are different, and the provider fulfills the other requirements for independent review, then I don't see why she couldn't get 3 points for viewing both films/studies.
 

coder21

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See they are not. She thinks she review what the ED provider/Rad since the ED provider order the CT report then she does her own visualization and documents in the chart her findings. So she thinks this is 3 points.
 

Pathos

True Blue
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Ok, I think I understand what you are saying now. If the provider reviews the CT and then does her own independent review, I would not count the data in both places. Either you can count the points in the Review/Order radiology, or in the independent review if she properly documented the independent review with some sort of summary of her own.
 
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MDM complexity reviwed

i have one real confusion regarding complexity data portion...IN inpatient setting, during hospital stay, if a provider reveiw the radiology report we give it one point, and if he also document the reports of previous 1 or two dates( that are already reveiwd in previous dates during that stay) can we give two points for it as old records reveiwed?? if not any CMS documentation?? really need help regarding this...thanks in advance
 
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