Learning ObjectivesImportance for patient careBilling rulesDocumentation priorities while in the roomFinishing your notes Practice for this week
Importance of MDM for Patient CareIt is what patients value from their doctorIt is why most of us went to medical schoolIt is what we want need to review when we
see the patient the next timeIt is what our coverage looks for when they
do a chart biopsyIt is what the jury considers when deciding
whether we acted reasonably, i.e. it is our malpractice defense!
Billing rules that shape your documentationIn order to bill a given level of Medical
Decision Making you must meet two of three criteria. The criteria are:
ProblemsData analysisRisk
ProblemsProblems/Differential Diagnoses Points
Self-limited or Minor (maximum of 2) 1
Established problem(s), stable, controlled, or at target 1
Established problem(s), worsening, uncontrolled, or not at target
2
New problem, no additional work-up planned 3
New problem, additional work-up planned 4
DataData Reviewed Points
Review/order clinical lab tests 1
Review/order diagnostic images (X-rays, CT, MR, ultrasound, nuclear)
1
Review/order other diagnostic tests (ECG, echo, PFTs, etc.) 1
Discussion of results with performing physician 1
Independent review of image, tracing, or specimen 2
Order old records 1
Review & summary of old records 2
RiskRisk Presenting
ProbsDx Procedures Mgmt Options
Minimal 1 self-limited (SL) or minor
Labs, images, or med test
Rest, non-pharm, & superficial
Low •2+ SL or minor•1 stable chronic•1 acute uncomp
•Non-stress tests•Contrast image•ABG or skin bx
•OTCs•Minor surg•PT/OT, Ivs
Moderate •1 unctrl chronic•2 ctrl chronic•1 new w/ risk
•Cardiac stress•Cardiac imaging
•Rx management•IVs with additives
High •1+ chronic w/ new end organ damage•Threat to life or bodily function•Abrupt change in neurologic status
•Cardiac contrast studies for sx•Cardiac EP studies•Endoscopic studies
•Parenteral controlled drugs•Drug therapy w/ toxicity monitoring•Palliative Care
Putting it togetherBest two out of three!MDM Complexity
Problems Data Risk
Straight Forward
1 1 Minimal
Low Complexity 2 2 Low
Mod. Complexity
3 3 Moderate
High Complexity
4 4 High
Priorities in the roomDiagnoses – You can leave them “naked”Orders
Medications – easiest using RxWriterImmunizationsLabsFuture Nurse Orders
Follow Up with causeInstructions
Finishing your noteMost efficiently done if you can complete before you
do your chart biopsy for your next patientIf you can’t, <Show Doc, Ctrl T> to save temporary
copyEdit/complete S: &O:“Clothe” your naked diagnoses with comments that
speak to items in Presenting Problem column of RiskIf “naked” they are minor and/or self-limitedStable chronic or uncomplicated (then you can add)Uncontrolled chronic or new with risk(s)End organ damage, threat to life, abrupt neuro change
Finishing your note - PlanEdit/Complete Orders not recorded in roomAdd management options that don’t rise to
the level of OrdersAdd Counseling/Coordination of Care Add you FTT name and CPT codeShow Doc & Print
Practice for this weekEnter your diagnoses while in exam or
preceptor room before patient leaves.Document all your orders before the patient
leaves.Write all your prescriptions using ezSOAP.Focus preceptor feedback on the O: and P:
portions of the note.
The final three lessons will be putting these skills together in specific kinds of visits.