Wiki Ob-gyn

[Ivonne C.]

I have a question regarding one of my physicians that I am auditing. He is an OB-GYN and currently has eCW. Sometimes there is no examination documented but they do a pelvic ultrasound on the same day that he reviews and documents. although the procedure is listed under the Plan of care can the documented ultrasund be used in the exam portion? Any help would be greatly appreciated.

Thanks,
Ivonne

 

[efrohna]

I have a question regarding one of my physicians that I am auditing. He is an OB-GYN and currently has eCW. Sometimes there is no examination documented but they do a pelvic ultrasound on the same day that he reviews and documents. although the procedure is listed under the Plan of care can the documented ultrasund be used in the exam portion? Any help would be greatly appreciated.

Thanks,
Ivonne

Hi Ivonne,
I would say "no." Reviewing or ordering ultrasounds are part of the medical decision making component. It would be under the categories of data to be reviewed and is given points towards the level of the MDM. I hope your physician knows that an exam is needed for new patients and consultations? However, if counseling or coordination of care is more than 50% of the visit, he/she may base the level on time.
Good luck!

 

[Ivonne C.]

Evangelina,
Thank you very much for you help, it has helped to confirm what I was thinking was the case. I will take that information and relay it to my physician.

Ivonne