# Number of Data points in MDM



## abhishekrane32@yahoo.com (Aug 1, 2012)

Good morning

I have a question regarding number of data points in  MDM section of EM

A  physician orders  the X ray of Wrist 
and also documents " I have reviewed the X- ray of wrist and it does not indicate Fracture"

how many data points will come?  do we have to give 1 data point for order in Radiology section and 2 points separately for independent visualization of Image.

Abhishek Rane


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## jvaugustine (Aug 2, 2012)

Looking at the MDM coding auditing tool,  I believe that a total of 3 points would be correct, 1 for ordering and 2 for independent visuaization of image.


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## mcarrillo (Aug 2, 2012)

I just asked this question yesterday, but no one answered, hmm.  I think counting 3 points is correct too.


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## Evelyn Kim (Aug 6, 2012)

I agree 3 points is correct.


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## MnTwins29 (Aug 7, 2012)

*Get specifics*

"I have reviewed X-ray" makes me a bit uncomfortable - is there documentation the physician really reviewed the FILM or simply a review of the report?


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## limpson (Aug 7, 2012)

If I were auditing this record, only 2 data points would be possible. 1 point is given if there is an order and/or review - OR - 2 points for an independent visualization (interpretation) of the film. The two points include the one point for the order. Awarding 3 points is a common error as on the surface, it appears that is what one can do.

That said, the statement "reviewed the x-ray" combined with his interp does beg the question - did the clinician look at the film independently or are they just re-capping the radiology report?

In my heart of hearts, I am sure it is their interpretation. However, documentation is what it is...and in this case seems contradictory.

Personally, I would query for clarification.


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## mcarrillo (Aug 12, 2012)

limpson,

What if the physician is documenting that he is visually reviewing an outside film? You would only give 1 pt? The coding auditing tool states 2 pts for this, and doesn't specify whether it is an in-house x-ray from their own radiology dept or an outside facility (hospital, radiology center, etc.). And also if the physician is visually reviewing the outside film, and then orders another x-ray (in-house or outside facility) because he wants a better or additional films, wouldn't this count as 3 pts?


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## rashmi (Aug 12, 2012)

Hi, 


I agree with 3 points (ORDERING-1,   INTERPRETATION-2)

Rashmi,CPC


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## rashmi (Aug 12, 2012)

Hi, 

I agree with 3 points ( ordering-1,  Interpretation-2)


RashmimaiRajan, CPC


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