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Data points
Part A-MDM: New problem with additional workup=4 points. Add’l workup (work done beyond visit) like xrays, labs, EKG, specialist referral/order, sent patient to ER/direct admit, decision for future procedure/surgery?
Then do you claim credit for those additional workups (xrays, labs, EKG) that were ordered as data points under part B-MDM: Amount &/or complexity of data reviewed?
MDM, diagnosis points
This is regarding the MDM, Diagnosis/Management points.
If doctor states at the end of his I&P, " I have considered the following conditions, being managed by patient’s other providers, during this visit: anxiety and fatigue." — Can these count as two problem points, one for anxiety and one for fatigue, or does doctor need to state that he has considered the conditions and that they are stable (or whatever the conditions status may be).
I appreciate any input regarding this. New to auditing and little nervous about it
TIA
KAM
ER coders/auditors that use a “grid” vs. points to establish E/M level of service.
Any information you would be willing to share would be greatly appreciated!
MDM Data points
If a test is done in the office & the physician does the visualization & interpretation of the result can you give them 2 data points under MDM? Tests are being billed. Noridian is our MAC but I can’t find anything regarding this when the tests are done in house.
Example:
Patient has PFT’s done in house by technician, the physician reads the tracing & interprets it & discusses the results with the patient & uses this information in their decision about treatment.
Any help is greatly appreciated!
points for amount of data
Data points for MDM
Electronic Medical Records (EMR) Vendors – Points to Consider
Selecting an EMR system for your medical practice is a very challenging task due to the rapid development in that field for last few years. According to a research, there are about 400 EMR vendors alone in the state of Los Angeles and California. Choosing the right EMR vendor is as important as choosing for the software itself. The element of reliability is very important because if it lacks that factor then there is no point of spending so much money on implementing EMR software for your medical practice.
So, if you are planning to have your own EMR system for practice, before buying the software the first thing that should be done is selection of the right EMR vendor. Following are the few points which will give you a guideline in carrying out the market research:
1. Checking the track record:
Evaluation of an EMR vendor can be done by reviewing their track record. Read the testimonials about their services and their success stories, this will help you in sorting out the right one for your requirements. Think of the EMR vendor as your partner and take a short interview before making up the final decision. Check the company history and their mission statement about the running business.
2. Evaluate your needs:
Before looking for an EMR vendor and getting confused with the services and features that they are offering, Make a clear list of what services and features that you actually require. This can be done by comparing it with the existing services you have implemented. This will save a lot your time once your clear with your depends or the type of system u want.
3. Consultation:
Before opting for EMR software, consult with different physicians who have been using the software for quite some time. Also, if you have any particular vendor in mind, check their clients and then compare and contrast with other vendors. Getting an opinion for complicated software like EMR is always beneficial in the long run.
4. Keep your questions ready:
Once you have evaluated your needs, and you are ready to go into the EMR market, make sure you have handful of important questions that are needed to ask. These questions can range from basic services to the more complicated ones including training procedures and the long term benefits. These Q/A sessions are extremely important because this would determine not only your commitment to your practice but also the efficiency of the vendor.
5. Training Issues:
Training is the backbone of the proper implementation of EMR system. Ask the vendor about their terms and conditions they are offering for training session. Learn about the onsite and online training manuals and demos. And also ask the vendor about the operating system and your requirements.
6. Manage your results:
After doing your market surveys write down your results. Don’t jump to any conclusions. It is wise to get back to your sales team or your staff, consult with them before making any final decision to proceed with a particular vendor. Also consider the differences very carefully because a physician with a newly established medical practice would be having different needs than the one who has been in business for a long time.
Daniel Ray MD Healthcare
EMR
EHR Systems
MDM data points for four separate biopsy/pathology
Patient has 4 separate lesions biopsies, each sent off for pathology (i.e., 88305×4).
For MDM data points, you get 1 point for ordering path (radiology). So how do you handle four separate lesions sent to path?
I can look at this two ways.
1. Similar to ordering clinical labs (e.g., blood work) you get 1 data point regardless of the number of blood tests ordered
or
2. Four separate problems are being addressed. The provider made the decision on four separate unrelated lesions, each having a potentially different diagnosis. I can consider this as having performed medical decision making four separate times, and would lean towards 88305 x 4 generating a total of four MDM data points
Anyone know of any carrier FAQs or other authoritative sources that might clarify this issue?
MDM Table B – Data Points
I have a doubt in MDM B table Related to the point, Independent visualization of labs or image – 2 points.
In chart
MD independently viewed and interpreted the Chest X-ray and also independently viewed and interpreted the Ultrasound lower extremity. Kindly guide me shall we consider it as 4 points or only 2 point because both are from the radiology section.
Thanks
Gunasekar.muthu