Obtaining Records and Obtaining History


Phoenix, AZ
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I have been going through some confusion regarding these data points and now I am trying to defend my case to my Drs

There are 2 criteria under the amount and/or complexity of date reviewed portion of MDM. This is what it says on the chart I was given, word for word

"Decision to obtain old records and/or obtain history from someone other than the patient" - 1 pt

"Review and summation of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider" - 2pts

The issue is when a Dr documents this-

"He is accompanied by his mother, who helps provide the history. I have reviewed all records available to me"

To me, this falls under the category which would give them 2 points. They do go on and summarize the patient's history along with what the parent provides. (I work in a children's hospital by the way)

The Drs have been arguing that they should receive 3 pts for reviewing and obtaining info from the parents. Based on what the chart I use says, it clearly states that reveiwing/summarizing records and obtaining info from someone else is under one umbrella and gets 2 pts. The other point is only when the provider MAKES the decision to obtain records/obtain history from someone that they do not have already. Drs think they can use the review/summaring as 2 and the obtain history from parent as 1. My manager and educator agree on this but it can vary by the notation of course. My manager argued that if the parent provides extra information that wasn't provided in the documents reviewed then they would indeed get 3 points. The information the parent provides has to be relevant of course and not just reporting current symptoms, but actual history.

I attached my chart (1) here as well as the chart the Dr said she was given as a tool (2)


View attachment Billing tool.pdf

Thanks for any feedback

Sometimes this isn't a huge deal but lately it's been the difference between a level 4 and 5 when the Dr wants that 5


True Blue
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I feel your pain on this one as I've been in the situation myself many times - this is a common type of problem that results from trying to assess complex MDM using a one-size-fits-all audit tool and of course different providers and auditors will always interpret these things differently. I don't have a silver bullet to offer, and really your organization should make an internal decision as to how you'll do this (with input from providers and auditors both) but I can share a couple of thoughts.

Regarding the use of the audit tool, I agree with you. Since we're talking about 'decision making' and not the taking of history, I understand these categories of points to apply to the provider's assessment and plan, and to mean that as a result of the provider's evaluation of the patient at the encounter, there is either a need for additional information not available at this time (therefore a decision to request/obtain), or that the provider has received this additional information (requiring information from outside sources to be reviewed). These are two distinct things and I could see in some circumstances that both of these could be present (e.g. the parent gives history not available from the patient that the provider needs to weigh, but then he or she also needs to request a hospital record before being able to make a diagnosis), but to credit both of these simply because the parent is giving the history is not really warranted. The fact that the parent is the one giving history certainly does increase complexity and risk, but that all by itself does not mean there is a separate 'decision' being made to get additional information.

But it also looks to me as though the electronic record is using a canned statement specifically aimed at get this box checked in the audit tool which may not necessarily reflect an increased level of complexity in the MDM. The documentation needs to reflect the actual complexity of the problem being evaluated. Beyond an interpretation of how to use the audit tool, what's more important is to take a step back and look at the big picture of what is the real complexity of MDM that you're looking at. In the MDM section of the 1995 guidelines, CMS discusses different elements that it calls 'indications' of the complexity of the data - the intent is that these elements are pointers or clues to the complexity and not absolute measures. Regarding this particular element, CMS says only that "A decision to obtain and review old medical records and/or obtain history from sources other than the patient increases the amount and complexity of data to be reviewed."

In my experience with payer auditors, when there's been a dispute about an E&M level, I've found that any appeal that relies just on counting points is likely not going to be successful. Payers will usually just come back and say something to effect that the documentation does not reflect that the patient required the highest level of care. Factors in the documentation that reflect the severity of the problem (e.g. new or worsening symptoms, the need for urgent tests or procedures, significant changes to the treatment plan, orders for consultations or follow-up within a short time frame, etc.) carry a lot more weight than how many points are tabulated. I think the best approach is that your organization look at a number of high level codes and assess whether the audit tool is taking your codes to the right place. Level 5 E&M codes should be reserved for the sickest patients or those with the most difficult or complex problems. The question everyone should be asking is whether the way the points are being counted is allowing providers to reach a level 5 for encounters that would more appropriately be coded as a lower level and whether ?

Sorry for a long-winded response. Hope this helps some and I'd be interested in hear others' input on this too.