Medical Documentation: Medical Decision Making Requirements

Documentation of Medical Decision Making

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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 Minimal Limited Multiple Extensive Amount or Complexity of Data to be Reviewed Minimal or None Limited Moderate Extensive Risk of Complications Morbidity or Mortality Minimal Low Moderate High Complexity of Decision Making Straightforward Low Moderate High out of elements must be met 22out of 33elements must be met 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Worksheets Calculating Documentation Levels HGSAdministrators Documentation Worksheet HGSAdministrators Documentation Worksheet CMS Medicare Part CMS Medicare Part BB Adapted from Adapted from Created by The Lung Doctor for e-Medtools History HPI: Status of chronic conditions □ 1-2 □ 3 □1 condition □2 conditions □3 conditions HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative PFSH □Past History □Family History □Social History Problem Focused □ Brief 1-3 □ Extended 4 or more □ None □ Pertinent to Problem 1 system □ Extended 2-9 Systems □ Complete 10 or more Systems □ None Expanded Problem Focused □ Pertinent 1 Detailed □ Complete 2 or 3 Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet 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 Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro Problem Focused Expanded Problem Focused □ 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 Detailed Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools 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 Problem status Self-limited or minor Established problem (to examiner) Stable or improved B Number Max = 2 x C Points = D Result 1 1 2 Established problem (to examiner) Worsening New problem (to examiner) No additional workup planned Max = 1 3 4 New problem (to examiner) Additional workup planned Total Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data Clinical lab tests reviewed and/or ordered 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) Points Result 1 1 1 1 1 2 2 TOTAL Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk Minimal Presenting Problem -1 self-limited or minor problem Dx Procedure Ordered -Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO -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 -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 -Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography Management Options Selected -Rest -Gargles -Elastic bandages Low -2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury -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 -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 -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 risk The highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Final Determination Complexity of Medical Decision Making A B C Number of diagnoses or treatment options Highest risk ≤1 Minimal Minimal 2 Limited Low 3 Multiple Moderate ≥4 Extensive High Amount and complexity of data reviewed ≤1 Minimal or Low 2 Limited Low Complexity 3 Multiple Moderate Complexity ≥4 Extensive High Complexity Type of decision making Straightforward Circle the appropriate descriptions for Rows A, B, C Circle the appropriate descriptions for Rows A, B, C The Column with or 3 circles determines the final Complexity of Medical Decision Making The Column with 22 or 3 circles determines the final Complexity of Medical Decision Making Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools

A concise summary of the medical documentation requirements for medical decision making based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

Medical Documentation: Medical Exam

Documentation of the Medical Exam

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Documentation of the Medical Exam Created by The Lung Doctor for e-Medtools Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes An extended exam of the affected body area An extended exam of the affected body area or organs/organ system and another Genitourinary (Female) or organs/organ system and another symptomatic or related area symptomatic or related area Genitourinary (Male) Hematologic/Lymphatic/Immunologic Musculoskeletal Comprehensive A general multi-system exam Neurologic A complete exam of an organ system and Psychiatric other related body areas or organ systems Respiratory Skin Most levels require a minimum of a Detailed Exam Most levels require a minimum of a Detailed Exam Created by The Lung Doctor for e-Medtools Multi-organ System Exam Detailed ≥3 vital signs BP, sitting or standing BP, supine Pulse, rate and regularity Respirations Temperature Height Weight ≥2 elements* of at least 6 organ systems or body areas examined OR ≥1 element of at least 12 organ systems Comprehensive ≥2 elements* in at least 9 organ systems or body areas *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Single Organ System Exam Detailed Document ≥12 elements* (NOT Eye and Psychiatric exams) Eye and Psych exams document ≥9 elements Comprehensive Document ALL elements* *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Elements of Individual Organ Systems Constitutional Vital signs General appearance of patient Nutrition, Body habitus, Development, Deformities, Grooming Cardiovascular Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities Eyes Inspection of conjunctivae and lids Exam of pupils and irises Ophthalmoscopic exam of optic discs Ears, Nose, Mouth and Throat External inspection of ears and nose Otoscopic exam Assessment of hearing Inspection of nasal mucosa, septum, and turbinates Inspection of lips, teeth and gums Exam of oropharynx Chest (Breasts) Inspection Palpation Gastrointestinal Abdominal exam Liver and spleen exam Hernia presence or absence Anus, perineum, rectum exam Stool for occult blood 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Neck Exam of neck Thyroid Respiratory Assessment of effort Percussion of chest Auscultation Palpation of chest Created by The Lung Doctor for e-Medtools Exam elements, continued Lymphatic Neck Axilla Groin Other Psychiatric Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect Musculoskeletal Gait and station Inspection, palpation digits and nails Exam of bones, joints, muscles AND 1 or more Inspection or palpation Range of motion and presence/absence of pain Stability Muscle strength and tone Genitourinary Male Scrotal contents Penis Digital rectal exam of prostate gland Female External genitalia Urethra Bladder exam Cervix Uterus Adnexa/parametria 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Skin Inspection Palpation Neurologic Cranial nerves Deep tendon reflexes Sensation Created by The Lung Doctor for e-Medtools

A concise summary of the medical documentation requirements for the medical exam based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

Medical Documentation: Medical History

Documentation of the Medical History

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The History Created by The Lung Doctor for e-Medtools History Components and Levels HPI Brief Brief Extended Extended ROS N/A Problem pertinent Extended Complete PFSH N/A N/A Pertinent Complete Type of History Problem Focused Expanded Problem Focused Detailed Comprehensive New patient evaluations MUST have at least a Detailed History Created by The Lung Doctor for e-Medtools History of Present Illness EVERY encounter MUST contain a Chief Complaint!  Preferentially stated in patients’ words Elements of HPI Location Brief Quality Contains 1-3 elements listed Severity Extended Duration Contains ≥ 4 elements Timing OR discusses 3 chronic or inactive conditions Context Modifying factors Associated Signs and Symptoms Created by The Lung Doctor for e-Medtools Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic Problem Pertinent Documents responses to the system directly related to the presenting problem Extended Documents positive and negative responses to 2-9 systems related to the problem Complete Documents all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total) Created by The Lung Doctor for e-Medtools Past, Family and Social History Past Medical History  Illnesses, Operations, Injuries and Treatments Family Medical History  Include heritable diseases and those that place the patient at increased risk Social History  An age appropriate review of past and current activities Pertinent Document at least 1 item from ANY of the 3 areas It must be directly related to the problems identified in the HPI Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools

A concise summary of the medical documentation requirements for the medical history based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.