Wiki Mdm

[allison_w_99]

I am still just a little confused by MDM. When taking into account the # of points that can be given for data to be reviewed when reporting SHC, can labs from the previous day be counted as long as it is documented as being reviewed? This is when the same data was already included in the inpatient follow up from the previous day.

 

[thomas7331]

If the review of labs was billed as part of the E&M charge for the previous day, I would not count it again toward a second E&M unless it was being done by a provider of a different specialty. Sounds more of a provider education and documentation quality issue as coders really shouldn't be asked to go back through previous notes to see if information is being repeated (unless performing an audit), each note should be able to stand on its own.