Wiki Labs placed into a note

[CScholer]

Hello everyone,
I am getting conflicting answers from our compliance team.
If a provider just copied and pasted the labs into the note, without further explanation or documentation of how it is relevant to the encounter, do you still count it as Moderate in the column of Amount and complexity of data reviewed?
Our compliance team says that we are to assume if they put it in a note that we can give them credit towards the "Review of results of each unique tests"
I was under the impression that "assuming " in a record was a no, no. and without eleaboration of the test we cannot give credit.

 

[thomas7331]

I agree with your reasoning and would not credit MDM for a simple copy/paste into a note without additional documentation. However, you need to follow your compliance team's guidance on this as they're the ones who are responsible for making decisions about your organization's risk tolerance.

I actually faced this exact same situation a number of years ago where the providers in our organization disagreed with the coders and argued that if the provider put the labs into the note, it should be considered self-evident that they reviewed the labs, and that any peer would agree that reviewing the labs is part of the service. My management sided with the providers and instructed the coding team to count the labs as having been reviewed.

 

[lgardner]

I agree with your reasoning and would not credit MDM for a simple copy/paste into a note without additional documentation. However, you need to follow your compliance team's guidance on this as they're the ones who are responsible for making decisions about your organization's risk tolerance.

I actually faced this exact same situation a number of years ago where the providers in our organization disagreed with the coders and argued that if the provider put the labs into the note, it should be considered self-evident that they reviewed the labs, and that any peer would agree that reviewing the labs is part of the service. My management sided with the providers and instructed the coding team to count the labs as having been reviewed.

I agree with Thomas 100%.

But I would add that hopefully, your compliance team has put this 'protocol' in writing. That way you are covered.