# labs reviewed



## lucymoon (Jul 10, 2013)

Hello, there has been some discussion about giving credit to physicians for "labs reviewed". One of the auditors stated that 'labs reviewed' must be followed by a date and description of which labs were reviewed, in order to give the MD credit toward the level. In the past, credit as been given for documenting just "labs reviewed". Thoughts?


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## dsantos1 (Jul 11, 2013)

I have to agree with that auditor.  Simply stating that "labs reviewed" is not enough information.  I have taught the providers I am responsible for that they must give a brief summary of the results and the date of the labs in order to get the credit.  

Deb Santos, CPC, CPMA


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## wrightju1 (Jul 11, 2013)

I disagree.  While it's not a bad idea to include the reviewed information, it is not required in order to give credit for having reviewed them.  They are a part of the medical record itself.  It is like giving credit for the ROS on the Patient Questionnare when the provider states that they have personnally reviewed the patient questionnare.  The labs are linked to the office note by stating that they have been reviewed.


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## FTessaBartels (Aug 5, 2013)

*1 data point or 2?*

Physicians get 1 data point for ORDERING -or- REVIEWING labs (ditto for X-rays).
So if the physician mentions getting a CBC (for example) that's all you need to award 1 data point (for determining MDM)

If the physician expects 2 data points for personally reviewing labs ... that means the physician personally viewed the sample (not just the lab report) ... i.e. he put that blood or urine sample under the microscope him/herself.   Or put the x-ray image up and looked at the film her/himself.   

Our surgeons frequently personally view the x-ray or ultrasound images, never look at the labs themselves. 

ALSO ... if you are going to charge a professional fee for interpreting labs, then you should not ALSO give 2 data points for medical decision making in the E/M.  That would be tantamount to being paid twice for the same work.


Hope that helps.

F Tessa Bartels, CPC, CEMC


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