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MDM/Categories of Data to be reviewed

  1. Default MDM/Categories of Data to be reviewed
    Medical Coding Books
    NPworking in Cardiologist's office. Sees patient, in her dictation it states

    "The plan of care is in collaboration with a doctor". On further questioning, she states she collaborated with a physician in her practice. She feels she should get points under the Categories of Data to be reviewed, specifically the Review and summarization of old records and/or obatining history other than the patient and/or discussion of case with another health care provider.

    Can anyone explain the discussion of case with another health care provider in a little more depth? I would imagine she needs to document who she spoke with and what the discussion was about.

  2. #2
    Default
    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

  3. #3
    Default Mdm
    Quote Originally Posted by tonyb View Post
    NPworking in Cardiologist's office. Sees patient, in her dictation it states

    "The plan of care is in collaboration with a doctor". On further questioning, she states she collaborated with a physician in her practice. She feels she should get points under the Categories of Data to be reviewed, specifically the Review and summarization of old records and/or obatining history other than the patient and/or discussion of case with another health care provider.

    Can anyone explain the discussion of case with another health care provider in a little more depth? I would imagine she needs to document who she spoke with and what the discussion was about.
    I guess my question is, isn't she supposed to collaborate with her physicians on the patient care? I guess I'm confused on why she would think this is separate. My opinion of collaboration would be outside her particular practice/office. Otherwise I would consider it part of the care needed for that patient in that office. I don't know that I have ever read anything that indicates one way or the other, but.... I'm confused on this one too. Sorry, can't be of more help than just giving my opinion here. Will be interested to see what other's say here.

  4. #4
    Default
    What is it that she actually documented?
    "... collaborated with a doctor" is very vague and I think part of what the NPs do.
    I would credit it if she documented something along the line that she discussed the case with the patient's PCP, or a specialist, or a social worker - nutritionist - ... you get the idea. It doesn't really have to be too much, but there has to be something to indicate that the conversation was in addition to what is regular collaboration.
    Karolina, CPC, CPMA, CEMC

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