Wiki Medical decision making

[Belarm3]

Good Morning,
When it comes to complexity of data reviewed in medical decision making, does the physician need to state what was discussed with the other physicians regarding the patient, or is it acceptable to simply state "spoke to Dr. Smith"? Also, if the physician states they spoke to 4 people, do each of those count separately? Appreciate any advice you can offer.
Thank you

 

[Jessim929]

In what context? I think that something like "Reviewed plan with patient, attending Dr,..." is different than "Consulted with <different specialty> regarding <separate ailment>..."

 

[Pathos]

The more documentation the provider can provide (up to a point), the more ironclad that sentence will be in a possible future audit. I would suggest the provider documents at least brief summary of what was discussed to help support those points for the MDM. As with anything in the Data section, you can only count each element once. That means, even if the provider looked at 11 lab studies, 8 xrays, and 3 echocardiograms, they would still get 3 Data points (1 point for each element). I think this was created to balance the amount of studies providers typically look over and the complexity and time of reading them. Most doctors look at many lab studies, and without this point limitation, would easily hit 4 Data point for almost every visit.


Hope this is helpful.