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Wiki Number of Data points in MDM

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abhishekrane32@yahoo.com

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Good morning

I have a question regarding number of data points in MDM section of EM

A physician orders the X ray of Wrist
and also documents " I have reviewed the X- ray of wrist and it does not indicate Fracture"

how many data points will come? do we have to give 1 data point for order in Radiology section and 2 points separately for independent visualization of Image.

Abhishek Rane
 
Looking at the MDM coding auditing tool, I believe that a total of 3 points would be correct, 1 for ordering and 2 for independent visuaization of image.
 
Get specifics

"I have reviewed X-ray" makes me a bit uncomfortable - is there documentation the physician really reviewed the FILM or simply a review of the report?
 
If I were auditing this record, only 2 data points would be possible. 1 point is given if there is an order and/or review - OR - 2 points for an independent visualization (interpretation) of the film. The two points include the one point for the order. Awarding 3 points is a common error as on the surface, it appears that is what one can do.

That said, the statement "reviewed the x-ray" combined with his interp does beg the question - did the clinician look at the film independently or are they just re-capping the radiology report?

In my heart of hearts, I am sure it is their interpretation. However, documentation is what it is...and in this case seems contradictory.

Personally, I would query for clarification.
 
limpson,

What if the physician is documenting that he is visually reviewing an outside film? You would only give 1 pt? The coding auditing tool states 2 pts for this, and doesn't specify whether it is an in-house x-ray from their own radiology dept or an outside facility (hospital, radiology center, etc.). And also if the physician is visually reviewing the outside film, and then orders another x-ray (in-house or outside facility) because he wants a better or additional films, wouldn't this count as 3 pts?
 
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