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Data points and MDM

  1. Default Data points and MDM
    Medical Coding Books
    My doctor usually has labs to review (1 Point). She always states that she personally reviewed the films (2 points), and she always says that she discussed the case in followup with the referring doctor (not just sending them a report). Does that count for two points, or does she have to be trying to find out information from another physician to be able to determine the dx to count the discussion with the referring doctor as two points?

    It would seem that this would be an easy 4 points, and if she was involved in a new problem with additional workup this would give her 4 points in two categories (diagnoses or management options) and (complexity of data reviewed) even if the level of risk was lower it would give her the 2 out of 3 elements.

    I understand that she has to reach the higher levels in the history and exam in order to meet the comprehensive level, but I am just trying to clarify if my thinking is correct per the MDM.



  2. #2
    Milwaukee WI
    Default Mdm
    I look at MDM as what goes into making the treatment / medical management decision.

    Reporting back to the referring doctor, in most cases, does not effect the decision making ... i.e. the decision on how to treat, or what additional tests to order has been made, and the physician is reporting back to the referring doctor. Whether that is done only with a written report, or done via a phone call or even in person is immaterial. This kind of communication is not part of making the decision. So I would NOT give 2 data points for these circumstances.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

  3. #3
    New Windsor, New York
    Default Another data points question
    If the pt arrives with pharangytis, our docs will administer a rapid strep test and inform the pt on the spot of the results. Now, does this count as one point for the ordering of the strep test, or three points with the ordering and visualization of the specimen? I am not comfortable with the three points, but one of our docs believes she should get credit for both. TY!

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