Wiki Pediatric MDM


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When auditing a pediatric problem visit, does anyone give credit/points for obtaining history from the parent? This would be for the medical decision making section of the amount and/or complexity of data reviewed. Would you, as the auditor, give 2 points for obtaining the history from the parent? Would the documentation have to specifically state the history was obtained from the parent or would you insinuate this information was obtained from the parent? Thanks!
Yes, I do award 2 points when obtaining history from a parent. And yes, it does have to specifically be documented. My providers and have discussed this in detail. If it is not documented, then it is not done and it doesn't matter if the patient is 8 days old. I tell them if they want credit, they have to document. Then they tell me I am counting beans! :D
I would not give credit for obtaining history from the parent when the child is too young to provide the history. The intent of data points is to give credit for additional work. If the physician is only obtaining history from one source, the parent, there is no additional work. I would only assign the 2 points when the child is older and able to give a history AND the physician obtains additional significant history from the parent. :)