We are a part of a multi-specialty physician practice that shares a single electronic medical record (EMR) and frequently perform services in the hospital/facility setting. If a physician reviews multiple records/notes from different specialists/specialties, are they only allowed one point under Data Category 1 for medical decision making (MDM) because we are part the same entity sharing one EMR? Or can a physician receive additional points for review of multiple reports/notes from different specialties? For example, if a physician reviewed a CT report interpreted by a radiologist, an operative note from a surgeon, and a pathology report interpreted by a pathologist, should the physician be able to receive 3 points under Data Category 1 “Review of prior external note(s) from each unique source” regardless if these records came from one hospital/facility (single EMR) as they are all different specialties/subspecialties? ...

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Note:  The following article synopsis was NOT provided by the AMA. It was created by Find-A-Code/innoviHealth.

Article Overview

This article discusses how current Evaluation and Management documentation guidance applies when a physician reviews notes, reports, or other records from multiple specialists in a shared hospital or facility EMR. It is aimed at clinicians, coders, and auditors who need to understand the general treatment of unique sources, data review, and medical decision making complexity under E/M guidelines. The article focuses on broad MDM data categories, source distinctions, and how those concepts relate to scoring or level selection without turning the premium content into a coding shortcut.

Why This Topic Matters

Accurate interpretation of E/M data review rules affects documentation quality, audit readiness, and level-of-service support when multiple specialties contribute information in the same record system.

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