Wiki E&M level for Observation admit MDM

[wynonna]

Hi fellow hospital coders:
E&M level for Observation admit MDM
I'm looking for how to count points under "Amount and/or Complexity of Data reviewed":
Our MD admitted to Observation unit: and info came from: Labs reviewed, history obtained from patient and from history recorded by ER physician, pulse oximetry recommended by our MD, multiple risk factors for chronic anticoagulation and epistaxis. Unclear as whether "Discussion with other health provider" took place. Can we count "review and summary of old records" or "obtaining hx from someone other than patient" count because our MD has to review and update history gathered by another MD in ER? How many total points under Data Review do you count?
thank you

 

[psd]

They would get 1 point for review of labs. If the pulse oximetry is being performed as a functional test (taking PO2 measurements during/after activity), they could get credit for ordering/reviewing *IF* they do not bill for the service.
To receive credit for "Discussion w/ other health care provider" they would need specifically state who they spoke with and what was discussed, outcome, etc.
To receive credit for "Review and summary of old records" they need to document what records they reviewed AND summarize them. Records from the same encounter, such as the ER physician preparing for admit would not count as old records.
To receive credit for "Obtaining hx from someone other than patient" Could be a family member, EMS/police, a provider of different specialty, etc. In order to get credit for this, the "someone other than patient" would need to provide additional information that could not be obtained from the patient. A family member/caregiver confirming what the patient already said doesn't add complexity and therefore would not get points.

Here is the MLN on E&M services, pages 16-17
https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/Downloads/eval-mgmt-serv-guide-ICN006764.pdf

 

[wynonna]

Thank you kindly for your expertise and the Medicare Learning Network link.