MDM - data points for general statement?

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Perri
Posts: 3
Joined: Tue May 22, 2018 6:16 pm
Location: Fountain Valley, California

Tue May 22, 2018 6:23 pm

I am starting to see this more and more in our provider chart notes - should any data points be given?

"I have reviewed and evaluated the following clinical information: vitals, laboratory results, imaging results, medications (including renal function adjustments if appropriate), nutrition and IV fluids and drips"
Bill_Wong
Posts: 11
Joined: Fri Apr 13, 2018 11:54 am

Wed May 23, 2018 5:07 pm

Hi Perri,

I would need to look at the complete documentation to see if the assigned MDM is supported. Some items that I would look for are:
1. Time stamp that the labs, radiographs, etc were indeed reviewed by provider; and/or
2. If the results of labs, radiographs, etc were pulled into provider report; and/or
3. Provider makes notation on his findings and reference the lab

If documentation is identical from patient to patient and you suspect templated notes or Cut & Paste (cloning), then I would speak with provider about that issue and correct that ASAP.
Bill Wong, CHC, CHPC, CCS, CPC, CPMA, CDEO
Corporate Compliance Analyst
Seattle Children's Hospital
Seattle, WA
Perri
Posts: 3
Joined: Tue May 22, 2018 6:16 pm
Location: Fountain Valley, California

Wed May 23, 2018 6:14 pm

Thank you Bill for your response! Usually all results do get pulled into the chart note but I've been noticing this statement just over the last couple of months. In this instance, the lab results were pulled in but not the Ultra Sound. I was able to see the electronic order for the US, but if I had not looked for it I would not have known that an US was even ordered by this provider, on this DOS.
Perri LoCicero, CPC, CPB
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