Q&A MDM for E/M

[metcalfpj]

Under the complexity portion of MDM for an E/M what exactly is the requirement to count data for the last line: Independent visualization of image, tracing or specimen itself (not simply review of record) worth 2 points.
Does that mean that that the physician has to interpret the record or do they just need to look at it?

 

[Alicia Scott]

The way I understand this to read is that to review the record is to read the findings in the chart. Now, if the physician looks at the specimen but does not write a report I still consider this worth the two points. However it must be documented that they did look at it. It might read, "After viewing the specimen I sent it to the lab for testing" So yes, they would only have to LOOK at the specimen to get credit and document that they did so. No report needed by the physician just documentation that they did in fact look or inspect it prior to sending it off.