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Question on E/M guidelines

  1. Question Question on E/M guidelines
    Medical Coding Books
    I have a few questions in regards to guidelines pertaining to points for Data Amount and Complexity.

    Clinical labs ordered or reviewed are worth one point.
    Radiology tests ordered or reviewed are worth one point.
    Any test(s) ordered or reviewed from the Medicine CPT section are worth one point.

    Do they need to be ordered by the same physician that reviews them? Do they need to be discussed with the patient and documentated in the note that this was done?

    In referance to review and summary of data from old records, example: physician documents that he/she reviewed hospital notes, labs, and x-rays, then proceeds to summarize all records. Is this considered 2 points only, for R&S or do they get an additional two points for documentation of review of labs and scans?

  2. #2
    Kansas City, MO
    Reviewer does not need to be the orderer. Does not need to be discussed with pt, but does need to be documented so we can tell they were reviewed.

    in R&S, you get the 2 points for the entire record...awarding extra points for sections within the same records (labs/xrays) is like double dipping.
    Linda Vargas, CPC, CPCO, CPMA, CPC-I, CEMC,CCC, AAPC Fellow
    PMCC Licensed Instructor
    2018 Chapter President, Kansas City, MO

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