Reviewing Records

KaylaRieken

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When providers see patients in the hospital and they review other prover's notes, should they get 2 data points for that? I am a little leary on this.
 
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Coeur d'Alene, Idaho
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I counsel my providers that in order to give them credit for reviewing other provider's notes, they need to document exactly what was reviewed and provide a summary as this option states "review and summarization". No summary, no credit.
 

KaylaRieken

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Should they get the 2 points thought if they are looking at other provider's H&Ps and progress notes while the patient is in the hospital?
 
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Coeur d'Alene, Idaho
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I don't know that there's really any official guidance on this. I, personally, feel that the provider would have to justify the medical necessity of reviewing the records, especially if they are wanting this credit for MDM on a daily basis. This is just my opinion.
 

thomas7331

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I think that if you take the guidelines in context, the data points for review of records is intended to give credit for the extra complexity and uncertainty involved when a provider needs to obtain and/or review data from an outside source, in other words, above and beyond what is available to them at the current encounter. Reviewing other providers' notes from the current hospital stay is routine and done with every inpatient E&M encounter, since providers are covering for each other and/or coordinating care plans, and, in and of itself, is to be expected and not a reason for additional complexity. I also agree that simply reviewing notes is not sufficient for credit - most guidelines do specifically state that the content must be summarized. (Incidentally, in the new documentation guidelines scheduled to go into effect in 2021 for office E&M services, there is clarification given that the MDM category for review of notes applies to external sources only so would not apply to reviewing the existing patient chart.)
 
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