Wiki Copied notes and MDM

[shihtzuaddict71]

If a provider copies and pastes part of a hospital note that contains MRI, CT, LAB results, etc. into their office visit, do you require the provider to document/note that they reviewed the information in order to use towards calculating towards complexity for the MDM? Or do you just assume that because they copied it that it is reviewed?

 

[jkyles]

If a provider copies and pastes part of a hospital note that contains MRI, CT, LAB results, etc. into their office visit, do you require the provider to document/note that they reviewed the information in order to use towards calculating towards complexity for the MDM? Or do you just assume that because they copied it that it is reviewed?

Hi there,
The provider needs to document what they did with the results (review, interpret, discuss with an external provider?) and tie that to their decision making for the visit. Some of the results may not be relevant to the visit. To the coder a bunch of test results are just a bunch of test results without more information from the provider.