The critical service you provideThe key driver to your reimbursement

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.