Documentation Of Medical Decision Making

Documentation of Medical Decision Making Created by The Lung Doctor for e-Medtools

Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality

Created by The Lung Doctor for e-Medtools

Complexity of Medical Decision Making Number of Diagnoses Or Management Options

Amount or Complexity of Data to be Reviewed

Risk of Complications Morbidity or Mortality

Complexity of Decision Making

Minimal

Minimal or None

Minimal

Straightforward

Limited

Limited

Low

Low

Multiple

Moderate

Moderate

Moderate

Extensive

Extensive

High

High

outofof33elements elementsmust mustbe bemet met 22out

Created by The Lung Doctor for e-Medtools

1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997

Worksheets Calculating Documentation Levels Adaptedfrom from Adapted

HGSAdministratorsDocumentation DocumentationWorksheet Worksheet HGSAdministrators CMSMedicare MedicarePart PartBB CMS

Created by The Lung Doctor for e-Medtools

History HPI:

□

□

□1 condition □2 conditions □3 conditions

1-2

3

HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms

□

□

Brief 1-3

Extended 4 or more

Status of chronic conditions

Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative

□

□

□

□

None

Pertinent to Problem 1 system

Extended 2-9 Systems

Complete 10 or more Systems

□

□

□

None

Pertinent 1

Complete 2 or 3

Expanded Problem Focused

Detailed

Comprehensive

PFSH □Past History □Family History □Social History Problem Focused

Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted

Created by The Lung Doctor for e-Medtools

Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity

□

□

□

□

1 Body Area or System

Up to 7 Body Areas or Systems

Up to 7 Body Areas or Systems

8 or more Body Areas or Systems

Problem Focused

Expanded Problem Focused

Detailed

Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro

Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted

Created by The Lung Doctor for e-Medtools

Comprehensive

Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making

• Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality

Created by The Lung Doctor for e-Medtools

Number of Diagnoses or Treatment Options Complexity of Medical Decision Making

A

B

x

C

Problem status

Number

Points

Self-limited or minor

Max = 2

1

Established problem (to examiner)

1

Stable or improved

Established problem (to examiner)

2

Worsening

New problem (to examiner)

Max = 1

3

No additional workup planned

New problem (to examiner)

4

Additional workup planned

Total Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted

Created by The Lung Doctor for e-Medtools

=

D Result

Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data

Points Result 1

Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT

1

Review and/or order of tests from medicine section of CPT

1

Discussion of test results with performing physician

1

Decision to obtain history from source other than patient

1

Review and summarization of history obtained from source other than patient

2

Independent visualization of image, tracing or specimen (NOT reviewing report)

2

TOTAL Adaptedfrom fromCMS CMSMedicare MedicarePart PartBB HGSAdministrators HGSAdministratorsDocumentation DocumentationWorksheet Worksheet Adapted

Created by The Lung Doctor for e-Medtools

Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk

Presenting Problem

Dx Procedure Ordered

Management Options Selected

Minimal

-1 self-limited or minor problem

-Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO

-Rest -Gargles -Elastic bandages

Low

-2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury

-Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies

-OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives

Moderate

-Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury

-Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis

-Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture

High

-Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status

-Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography

-Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis

Thehighest highestlevel levelininANY ANYcategory categorydetermines determinesthe theoverall overallrisk risk The

Created by The Lung Doctor for e-Medtools

1997Guidelines Guidelinesfor forEvaluation Evaluation&&Management ManagementServices Services 1997

Final Determination Complexity of Medical Decision Making A

Number of diagnoses or treatment options

≤1 Minimal

2 Limited

3 Multiple

≥4 Extensive

B

Highest risk

Minimal

Low

Moderate

High

C

Amount and complexity of data reviewed

≤1 Minimal or Low

2 Limited

3 Multiple

≥4 Extensive

Low Complexity

Moderate Complexity

High Complexity

Type of decision making Straightforward

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Created by The Lung Doctor for e-Medtools