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MDM question for E&M audit....

  1. #1
    Default MDM question for E&M audit....
    Medical Coding Books
    If the doctor writes under the plan pt have labs drawn (specifies with tests) in 2 months for the next visit does that count as 1 point for ordering labs?

    Thank you for your help!!
    Julie Dale, CPC

  2. #2
    Concord, NC or Rochester, NY
    That would count for the Complexity of Data in the MDM as it has been ordered

  3. #3
    White Plains, NY
    Default I disagree
    The test has NOT been ordered. It has been noted to be ordered in the future; unless you can produce the Rx in the record, I would not count it.
    The physician also did not specify that labs be drawn prior to next visit.

    What of this scenario - this is counted towards the MDM now, but labs are not done for two months. Then at the next encounter (2 months later) bloods are obtained and the labs are done as planned. Which encounter is it appropriate to count it for? You can't count it as an element for both encounters.


  4. #4
    Thank you Lin! That answered my question!

  5. #5
    Default Janet
    I agree entry by losborn. Lab Data only counts in one of two ways.
    1. The provider reported the labs in his notes = 1 point


    2. The provider ordered labs for that day = 1 point
    You only get credit for one or the other but never both. Noting that labs will be drawn in the future is not an official order.

    Hope that helps. Data points are a stumbling block for lots of people. Remember too that they aren't even actually REQUIRED by CMS it is just this evaluation system that somehow everyone seemed to adopt and now it is law when in reality it isn't. Good Luck

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