Wiki MDM- Review of old records

[tspangler72]

Hello,

When reviewing labs/tests from the day before during an inpatient stay would you give 1 point for review of data or 2 points for review of old records?

This has become quite the hot discussion in our office.

TIA

 

[dclark7]

I would only give one point for review of lab/tests. The E/M Documentation Guidelines regarding review of old records state "Relevant findings from the review of old records...........to supplement that from the patient should be documented......." In my opinion (and this is just my opinion) this means you need to actually review old records and you cannot use this section for review of labs or other tests.