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E/M Data Reviewed Points HELP

  1. #11
    North Carolina
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    But...It doesn't state HE ordered the studies. This could have been ordered in the ER and he is providing an interp based on those studies ordered by another physician.
    Rebecca CPC, CPMA, CEMC

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  2. #12
    White Plains, NY
    Default Follow up
    AK - the physician cannot take credit for the visualization of a test conducted on the same DOS in the Data Points, but can he/she take credit for ORDERING the procedure in the data points?



  3. #13
    Default Claification in Data points
    If the physician Orders for labs it qualifies for 1 point.

    Please clarify if the same physician Cancel the order latter.

    1. Due to Patient not willing or not affordable.
    2. Due to Physician decision on not necessary for labs.

    Thanks much,

  4. Default
    Quote Originally Posted by RebeccaWoodward* View Post

    Order of 2V CXR, 1V of shoulder, and 1V of the hip= 1 point

    Quick question on this... I see this is an older thread, but I'm having a hard time finding this information anywhere.
    Does it matter if all images reviewed were x-rays or if the physician reviewed X-ray AND an US or CT, etc...?
    Basically, is this 1 point regardless number of images or types of imaging within the radiology section?

  5. #15
    The provider can only be credited 1 point for ALL information reviewed/ordered of that type of information (labs, radiology, medical studies, etc.). The only exception to this rule, would be if the physician Independently reviewed the studies/images before another expert could review and document. This would typically require the provider to state in his/her own words what the report indicated.

    Hope this helps!
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  6. Default Independent review of films AND radiologist report
    If a provider documents that he personally view the xray films/scans and documents his impression. He then reviews the radiologist report/impression and documents that information. He now compares the 2 impressions and documents that information. Would he get 2 data points for independent visualization of xray films/scans w/ impression and another (1) data point for review of the radiologist report/impression? The has documented that he has done the work of 2 separate actions. Or would this be double dipping?

    Thanks in advance

  7. #17

    Because the provider is using the same study, I would go with the Independent Review only. The CMS E/M guidelines explain:

    "DG: The direct visualization and independent interpretation of an image, tracing, or specimen previously or subsequently interpreted by another physician should be documented. "

    Because of the description of the above, this action suggests that the provider is already reading the study "previously interpreted by another physician", thus counting both the Independent Review AND review of the report, would in my opinion be "double dipping".

    Hope that helps!
    "When you have exhausted all possibilities, remember this: You haven't!"
    -Thomas Edison

  8. Default Independent review of films AND radiologist report
    Yes that was very helpful.

    Thank you!!

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