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MDM question

  1. #1
    Default MDM question
    Medical Coding Books
    When a patient has a urinalysis in the office and the result are on the office note and the doctor comments on the results being normal, is that considered an "independent review of image,tracing or specimen? Another question, if the doctor gives a prescription for a contraceptive is that considered "prescription drug managment". Is any prescription considered "drug management"?

    Thanks for your help,

  2. #2
    Location
    Tacoma, WA
    Posts
    1,087
    Default
    Quote Originally Posted by julia9723 View Post
    When a patient has a urinalysis in the office and the result are on the office note and the doctor comments on the results being normal, is that considered an "independent review of image,tracing or specimen? Another question, if the doctor gives a prescription for a contraceptive is that considered "prescription drug managment". Is any prescription considered "drug management"?

    Thanks for your help,
    The doctor's comment on the lab test is a review of a specimen. Any prescription counts for prescription drug management.
    Arlene J. Smith, CPC, CPMA, CEMC, COBGC

  3. #3
    Default
    thank you

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Independent Review
    Independent review means the doctor actually looked at the urine sample himself under the microscope to ascertain the presence (or abscence) of microbes.

    Reviewing the lab report - even if he summarizes it in his note - is NOT the same as independently reviewing the specimen.

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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