If documentation only states that the patient has a condition treated by another provider, how is this treated for MDM leveling?

If documentation only states that the patient has a condition treated by another provider, how is this treated for MDM leveling?

• A. It is not considered for leveling unless there is additional documentation showing assessment or care coordination
• B. It is always counted toward the level
• C. It is never counted toward the level
• D. It is counted only if the patient is seen by the same provider

Answer: (A)

In MDM, you earn credit for what you actively do during the encounter: how many problems you address, what data you review, and the level of risk involved in the management decisions. If the chart only notes that the patient has a condition treated by another provider, with no documentation of your own assessment, plan, or care coordination related to that condition, it doesn’t add to the MDM. It’s not until there’s additional documentation showing you assessed the issue or coordinated care with the other provider (or otherwise integrated management decisions) that it would count toward the level. So, this scenario is not counted for leveling unless a separate note demonstrates assessment or care coordination.

In MDM, you earn credit for what you actively do during the encounter: how many problems you address, what data you review, and the level of risk involved in the management decisions. If the chart only notes that the patient has a condition treated by another provider, with no documentation of your own assessment, plan, or care coordination related to that condition, it doesn’t add to the MDM. It’s not until there’s additional documentation showing you assessed the issue or coordinated care with the other provider (or otherwise integrated management decisions) that it would count toward the level. So, this scenario is not counted for leveling unless a separate note demonstrates assessment or care coordination.