# e/m data points



## kimgiz (Apr 13, 2010)

I have a question about data points for MDM. Below is an example of data documentation I would appreciate any feedback on how may points you would assign. Example is as follows:
BMP is remarkable for a potassium of 3.5 and a glucose of 144. Total
bilirubin is also slightly elevated at 1.4.CBC shows a hemoglobin of
14.6; WBC 9.2; platelet count 193,000; 63 polys, 11 monocytes. PT is 12.
CT of brain without IV contrast, reveals unchanged deep penetrating artery infarct in the anterior left corona radiata. There is no evidence of acute infarct, hemorrhage, mass or mass effect. The EKG, independently reviewed by me, reveals sinus rhythm at 70 with normal axis, QTc prolongation, but no acute ST-T wave changes. There are nonspecific ST-T wave changes. Chest x-ray, also independently reviewed by me, reveals no acute disease with healed rib fracture on the right.
any help appreciated, thanks


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## FTessaBartels (Apr 13, 2010)

*Data points*

You get 1 point for review and/or order clinical lab tests (one test or 40 tests - you still get just 1 point).

You get 1 point for review and/or order tests in the radiology section (you have both a CT and CXR - still just 1 point)

You get 1 point for review and/or order of tests in the medicine section (you have an EKG - 1 point)

I cannot tell from this documentation whether the physician personally viewed the image,tracing or specimen.  If the physician had clearly documented that s/he personally was viewing the CXR or EKG (for example), you would assign another 2 points (no multiplier - personally view one or 40 xrays you get 2 points)

Hope that helps.

F Tessa Bartels, CPC, CEMC


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## kimgiz (Apr 13, 2010)

Thanks for your help, 
let say yes they personally reviewed the EKG imaging,
then you points would total 4????
appreciate your input
thanks 
kim


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## FTessaBartels (Apr 14, 2010)

*Personal review*

Personally viewing is *not* documented in the sample you provided, so I would not give credit for that. 

However *if *personally viewing IS documented you get 1 point for ordering/reviewing the test, and another 2 points for personally viewing the tracing/specimen/film.

Hope that helps.

F Tessa Bartels, CPC, CEMC


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