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Medical Decision Making Tool


Best answers
Can you capture a patient referral for consultation documented in progress note under assessment/plan in the MDM? If yes, is there any website or guidelines to back this up?



Best answers
If the patient is referred to another physician for care----no
If a consult is requested from another physician----yes

Texas Trailblazer allows 1 point under the Data Portion of MDM

"Discuss case with other physician(s) involved in patient’s care or consult another physician (i.e., true consultation meaning seeking opinion or advice of another physician regarding the patient’s care). This does not include referring patient to another physician for future care."

Here is a link to their audit tool

http://www.trailblazerhealth.com/Publications/Job Aid/coding pocket reference.pdf
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