If a laboratory test result from 5-7 years ago is copied and pasted for a current encounter without any comments about the test documented, can credit be granted for review of a unique test in the medical decision making (MDM) element of the Amount and/or Complexity Data to be Reviewed and Analyzed category? ...
Subscribe or sign in to view the full article.
Article Overview
This article explains a documentation scenario in evaluation and management coding where an older laboratory result is copied into a current note. It focuses on how review and analysis of prior test information may be considered in the medical decision making data element, and why simple copied material without additional documentation may not support credit. The guidance is relevant to clinicians, coders, auditors, and compliance teams working with E/M documentation.
Why This Topic Matters
Correctly documenting review of prior test data can affect how medical decision making is supported in an encounter note. The article helps reduce inappropriate crediting of copied information and supports more consistent auditing and compliance review.
What You Will Learn
- How older test results may be treated in the data-review portion of medical decision making
- Why copied documentation alone may not be sufficient for credit
- What kinds of documentation may support that prior data contributed to current analysis
- How this issue relates to E/M encounter documentation and review of data
Who Should Read This
- Physicians
- Advanced practice providers
- Medical coders
- Clinical documentation specialists
- Compliance auditors
Subscribe or sign in to view the full article.
Quick, Current, Complete - www.findacode.com