You are correct. The only way to get credit for something is if it is documented.
She would need to tell who the other provider is, what was discussed, and the outcome.
The way it is documented makes me think this is a split/shared or incident to visit, not a piece of MDM.
The first thing that popped into my mind was, does it even matter? It is not often that data makes a big difference on the outpatient side. I'm not saying it doesn't ever, but look at the big picture and don't stress over things that won't change the end result. If you already have 4 dx points and moderate risk, 2 data points won't make a difference.
There are some providers that will actually pad their data points to get higher levels, I have been in meetings where this was promoted, so I may be a little jaded on the data points issue.
Laura, CPC, CEMC
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