Medical Decision Making

What we all went to medical school to do!Bryan L. Goddard, M.D.August 2010

Starting with the end in mindWhy we are starting with MDM instead of H&PAssessments are more than ICD codesTreatments that aren’t structured

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MDM defines what History and PE counts and is requiredHistory unrelated to MDM is ROS and rarely

changes billable servicePE findings are countable only if needed by MDM,

e.g. 7 pt. Musculoskeletal exam for hypertension not warranted!

History that results in orders, but is not documented, is “money left on the table!”

In Family Medicine, counseling and/or coordination of care drives billing in 1/3 of visits

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Getting everything inBy requiring diagnoses to write orders, eCW

“forces” you to add diagnoses to support ordersMake sure the Principal diagnosis has X on it, even

if not the top because you nurse ordered symptom-driven labs or immunizations, e.g. Patient requested pregnancy test due to late period at visit for headaches.

If >4 diagnoses, make sure the ones that affect the billing are in the top four lines.

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Making sure your Problem Points count

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Avoid Naked Diagnoses!A “naked diagnosis” is a diagnosis without thinking

behind it. Educationally, clothing your diagnoses will help you

remember what you learned through discussion with preceptor

Patient care will benefit if patient is seen by your coverage or after you’ve forgotten what you were thinking

Billing is enhanced when you describe the Risk and/or interaction with other diagnoses

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Where to put the “clothes”Specify – This is a good place for brief comments

like “New,” “Controlled,” “At target,” “Terminal,” etc. that speak to MDM points

Notes – Since these are assigned by diagnosis, this area is ideal for “analysis” i.e. differential diagnosis, thoughts about likelihood, reasons why not controlled, etc. The patient will not see these notes.

Free text field at bottom – This follows the entire list and is a good place for “synthesis,” i.e. when you put things together, e.g. DJD of knee, diabetes out of control, & back pain all related to morbid obesity.

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Creating your Assessment Comments in eCW

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What the final note looks like

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TreatmentsStructured orders – lab, DI, procedures, & referrals

drive most of the points of MDMText fields on Treatment screen print on Visit

Summary, so keep it understandable by patient (alternatives: enter in assessment or after printing Visit Summary)

Synthesis counseling can be documented under OthersCounseling/Coordination of Care (that drive 1/3 of

billing!) can be documented in the Notes field at bottom – preferably on Other Tab when there are multiple assessments

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Tools to help document MDM in eCW

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←Progress Note

Visit Summary ↑

Preceptor documentation of supervisionOnce you have documented your MDM, your

preceptor should be able to document his/her supervision

Print DI orders for Black Out-GuidesHyperlinks will be in note for them to use to

document approval of referrals.

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