Wiki Need help with MDM Data points

[sjsantjer]

Can you count reviewing your clinics records on (established patient) as a Review and Summation of old records? I thought the review of old records was for outside records or a hospital chart, not your own office chart?? Doctor states in the note “Data reviewed: Summary of review of old records and/or additional history to supplement that obtained from patient”. He is not doing a separate summary, but states that it is in the HPI. When I run through the HPI it all count as HPI points. Can we do count this? Does anyone have any suggestions or documentation that would help?? Thank you.

 

[sjsantjer]

Any Thoughts?

Any thoughts??

 

[LLovett]

My thoughts are no, this does not count

The data points you are referring to are not part of either set of the official guidelines so it could be a little more complex than a yes or no to this question.

Some carriers use them. Some don't tell us what they use (i.e. WPS Medicare).

If I was using the data points I would not count this b/c it states to summarize the old records. Not tell me you summarized them, actually give a summary of the old records. If we take this a step further it seems clear to me the intent was when dealing with records that are not your own.

The guidelines, while not assigning a point value, do clearly state the following:

"!DG: Relevant finding from the review of old records, and/or the receipt of
additional history from the family, caretaker or other source should be
documented. If there is no relevant information beyond that already obtained,
that fact should be documented. A notation of "Old records reviewed" or
"additional history obtained from family" without elaboration is insufficient."

The other issue you have is the fact they are trying to double dip. This is either HPI or MDM, can't be both.

Just my take on the situation for what its worth,

Laura, CPC, CPMA, CEMC