Wiki E&M 2021 Guidelines for middle column of audit Tool: Amount/complexity of data to be reviewed/analyzed

[wynonna]

Category 1: Tests and documents lists: under bullet #1: "Review of prior external notes from each unique source"
So what does this mean? Prior office notes from a different provider within same ENT practice? From a referring PCP?
Any thoughts or examples of what constitutes "Prior external notes from a unique source?"
Thank you fellow coders.

 

[csperoni]

Category 1: Tests and documents lists: under bullet #1: "Review of prior external notes from each unique source"
So what does this mean? Prior office notes from a different provider within same ENT practice? From a referring PCP?
Any thoughts or examples of what constitutes "Prior external notes from a unique source?"
Thank you fellow coders.

Notes from another physician in the same practice would not be external notes.
I would count notes from referring PCP.
Example for my practice:
Patient referred by ob/gyn for pelvic pain, was also recently seen by GI for workup. We obtain the notes from both the referring ob/gyn and the GI. That would count for 2 of the "review of prior external notes from each unique source."
I think this would be used mainly for specialists reviewing referring physician records. Or PCP reviewing specialist's consult note. (Please be aware I am using the word consult here in a loose sense, not in the coding definition of consultation.)

 

[zcometa]

Category 1: Tests and documents lists: under bullet #1: "Review of prior external notes from each unique source"
So what does this mean? Prior office notes from a different provider within same ENT practice? From a referring PCP?
Any thoughts or examples of what constitutes "Prior external notes from a unique source?"
Thank you fellow coders.

I would be very curious to know as well. we are a GI group and we are partnering with a larger medical group in the middle of 2021 which includes other specialties and primary care providers. Would the notes from other providers within that medical group then not be considered external, even though they are from a different specialty?

 

[zcometa]

Category 1: Tests and documents lists: under bullet #1: "Review of prior external notes from each unique source"
So what does this mean? Prior office notes from a different provider within same ENT practice? From a referring PCP?
Any thoughts or examples of what constitutes "Prior external notes from a unique source?"
Thank you fellow coders.

As long as they are of a different specialty you can count the notes from another MD/NP/PA/QHP in your practice

External physician or other qualified healthcare professional: An external physician or other qualified health care professional is an individual who is not in the same group practice or is a different specialty or subspecialty. It includes licensed professionals that are practicing independently. It may also be a facility or organizational provider such as a hospital, nursing facility, or home health care agency.

• When the data section discusses review of external records, count records from a physician/NP/PA within your multi-specialty group, but who has a different specialty are considered.
• Don’t include records from your same specialty partners.

Souce: https://www.lsuhn.com/mdm-2021-tip5/