Created by The Lung Doctor for e-Medtools

Documentation of Documentation of Medical Decision Medical Decision

MakingMaking

Created by The Lung Doctor for e-Medtools

Elements of Medical Decision MakingElements 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 MakingComplexity of Medical Decision Making

Number of DiagnosesOr 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

2 out of 3 elements must be met2 out of 3 elements must be met 1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services

Created by The Lung Doctor for e-Medtools

WorksheetsWorksheetsCalculating Documentation LevelsCalculating Documentation Levels

Adapted fromHGSAdministrators Documentation Worksheet

CMS Medicare Part B

Adapted fromHGSAdministrators Documentation Worksheet

CMS Medicare Part B

Created by The Lung Doctor for e-Medtools

HistoryHistoryHPI: Status of chronic conditions□1 condition □2 conditions □3 conditions

□1-2

□3

HPI elements□Location □Severity □Timing □Modifying factors

□Quality □Duration □Context □Associated signs & symptoms

□Brief1-3

□Extended4 or more

Review of Systems□Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes

□CV □MS □Neuro □Aller/Immun □Resp □Psych

□All others negative

□None

□Pertinent to

Problem1 system

□Extended

2-9 Systems

□Complete

10 or more Systems

PFSH□Past History □Family History □Social History

□None

□Pertinent

1

□Complete

2 or 3

Problem Focused

Expanded Problem Focused

Detailed Comprehensive

Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet

Created by The Lung Doctor for e-Medtools

ExaminationExaminationBody Areas□Head, Face □Chest, Breasts, Axilla

□Abdomen □Neck □Back, Spine

□Genitalia, Groin, Buttocks □Each Extremity

Organ Systems□Constitutional □ENT □Resp □MS □GI □Skin

□GU □Psych □CV □Eyes □Heme/Lymph □Neuro

□1

Body Areaor

System

□Up to 7

Body Areas or

Systems

□Up to 7Body Areas

orSystems

□8 or more

Body Areasor

Systems

Problem Focused

ExpandedProblem Focused

Detailed Comprehensive

Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet

Created by The Lung Doctor for e-Medtools

Medical Decision MakingMedical 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 OptionsNumber of Diagnoses or Treatment OptionsComplexity of Medical Decision MakingComplexity of Medical Decision Making

A B x C = DProblem status Number Points Result

Self-limited or minor Max = 2 1Established problem (to examiner)

Stable or improved1

Established problem (to examiner)Worsening

2

New problem (to examiner)No additional workup planned

Max = 1 3

New problem (to examiner)Additional workup planned

4

Total

Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet

Created by The Lung Doctor for e-Medtools

Amount and/or Complexity of Data ReviewedAmount and/or Complexity of Data ReviewedComplexity of Medical Decision MakingComplexity of Medical Decision Making

Reviewed Data Points ResultClinical lab tests reviewed and/or ordered 1

1

1

1

1

2

2

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

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

Discussion of test results with performing physician

Decision to obtain history from source other than patient

Review and summarization of history obtained from source other than patient

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

TOTAL

Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet

Created by The Lung Doctor for e-Medtools

Guide to Determining Guide to Determining Risk of ComplicationsRisk of ComplicationsComplexity of Medical Decision MakingComplexity of Medical Decision Making

Risk Presenting Problem Dx Procedure Ordered Management Options SelectedMinimal -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 stressCardiac stress testCardiopulmonary exercise test

-Diagnostic endoscopies with NO risk factors-Deep needle or incisional biopsy-Cardiovascular imaging studies with contrast

NO identifiable risk factorsCardiac catheterization

-Obtaining body cavity fluidThoracentesis

-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

The highest level in ANY category determines the overall riskThe highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation & Management Services1997 Guidelines for Evaluation & Management Services

Created by The Lung Doctor for e-Medtools

Final Determination Final Determination Complexity of Medical Decision MakingComplexity of Medical Decision Making

A Number of diagnoses or treatment options

≤ 1Minimal

2Limited

3Multiple

≥4Extensive

B Highest risk Minimal Low Moderate High

≥4Extensive

High Complexity

C Amount and complexity of data reviewed

≤ 1Minimal or Low

2Limited

3Multiple

Type of decision making Straightforward Low Complexity

Moderate Complexity

Circle the appropriate descriptions for Rows A, B, CThe Column with 2 or 3 circles determines the final Complexity of Medical Decision Making

Circle the appropriate descriptions for Rows A, B, CThe Column with 2 or 3 circles determines the final Complexity of Medical Decision Making

Adapted from CMS Medicare Part B HGSAdministrators Documentation WorksheetAdapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet