Wiki Mdm

[jmcalhaney]

I was wondering if anyone could tell me if I can count 1 data point for the Dr. stating that the patient had a bidirectional endoscopy done on 5/10/10 and was found to have Barret's esophagus. The patient is being seen for epigastric discomfort and reflux. It seems to me that the Dr. is reviewing the test, but I am not sure if this should count since it was 2 years prior.

The physician office I am coding for often lists previous tests and the results of them in the HPI note. I am confused on whether or not I can count these. Any guidance given is appreciated. If there is a website or instructional guidance that you can recommend, please do.

Thanks

 

[Naveen Rachagolla]

Since the physician is using the previous records or test and after going through them Dr. stating that the patient had a bidirectional endoscopy done on 5/10/10 and was found to have Barret's esophagus.

Even though he dint ordered but he is reviewing so obviously he will get one point,

This you can find in the MDM table itself.

 

[FTessaBartels]

Wait a minute

Is he actually reviewing this report OR is he just reciting past medical history?

If the former, yes you can count this in the data review
If the latter, no, it doesn't count in data reviewed ... it DOES count for past medical history.

Hope that helps.

F Tessa Bartels, CPC, CEMC

 

[Naveen Rachagolla]

Is he actually reviewing this report OR is he just reciting past medical history?

If the former, yes you can count this in the data review
If the latter, no, it doesn't count in data reviewed ... it DOES count for past medical history.

Hope that helps.

F Tessa Bartels, CPC, CEMC

Tessa can u please explain what that two words means, The former and latter, i dint get what you r trying to say ?

 

[jmcalhaney]

Is he actually reviewing this report OR is he just reciting past medical history?

If the former, yes you can count this in the data review
If the latter, no, it doesn't count in data reviewed ... it DOES count for past medical history.

Hope that helps.

F Tessa Bartels, CPC, CEMC

Thats what I was wondering myself. I am not located in the physician office and only audit the charts. I was having trouble deciding whether or not he was actually reviewing the report. I guess that I would have to actually ask the Physician what he is actually doing here.