Two questions about counting data reviewed

Hello,

I would like to find out from others how you would count these areas under the MDM / data reviewed section of the audit:

1) "Personally reviewed CT report" This is all, no interpretation or anything else. 1 point for review of radiology or 2 points for independent visualization. I was taught that the provider had to document that they reviewed and their interpretation of it.

2) "Reviewed old records: in Epic" Epic is our own EHR, so they are not getting records from outside of our own health system. I am in a different carrier region now, but the old one I was in stated that your own health system's EHR did not count as a decision to obtain or review old records.

Thank you

re: Two questions about counting data reviewed

as far as I've been informed or know, I must agree with your understanding of the need for 'qualifiers' for the MDM notations in an E&M note from a prescriber (item 1); for item 2: according to my understanding of what I've read and researched, reviewing ones OWN charts is NOT included as a qualifier here. For what this is worth, given it is my 'understanding', too. OTHERS???

re: Two questions about counting data reviewed

Personally reviewed: I think if you go to the Documentation Guidelines, you won't find that requirement. The DG say:

DG: The direct visualization and independent interpretation of an image, tracing or specimen previously or subsequently interpreted by another physician should be documented.

As for reviewing one's own records, I agree: not extra data.