The Clinically Correct Coding (C3) Series The Basics of Evaluation and Management: Getting Paid for What You Think

1
The Clinically Correct Coding (C3) Series The
Basics of Evaluation and Management Getting
Paid for What You Think

• The Grand Strand Advanced Practice Nurse
  Associations Lecture at the Beach
• Nick Ulmer, MD CPC
• VP Clinical Services and
• Medical Director of Case Management
• Spartanburg Regional Healthcare System
• Staff Physician
• MGC - Family Medicine Five Forks

2
Basic E/M Objectives

• Be understanding of the key component of the
  history of an encounter and how it relates to
  correct coding (Session I)
• Know the mnemonics associated with the history
  and examination components and how they relate to
  correct documentation and coding of an encounter
  (Session II)
• Understand medical decision-making and how it
  relates to the clinically correct coding of an
  encounter (Session III)

3
Disclaimer

• E. G. Nick Ulmer, Jr., MD CPC is the owner of
  the entire content of this presentation. Any
  questions related to interpretation of the coding
  rules discussed herein should be directed to Dr.
  Ulmer at
• NUlmer_at_ProTimeLLC.com or
• 864-684-4248 (cell/text)
• Spartanburg Regional Healthcare System is in no
  way related to the educational content of this
  presentation.

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Objectives for the history session

• Understand the building blocks of the history
  that are needed to construct an office note for
  new and established patients
• Realize the clinical make-up of the history of
  present illness, system review, and
  past/family/social history
• Know the mnemonics described to allow rapid
  recall of these components in clinically correct
  documentation of an encounter

5
Evaluation and Management Components

• Key Components
• History
• Exam
• Medical Decision Making
• Contributory Components
• Counseling
• Time

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Some history.

• 1992 started by AMA and CMS
• 1995 first revision
• 1997 the bullet points, provided a single
  examination option for individual organ systems
• Insurance companies use these guidelines for
  verification of work done in an
  encounter/procedure
• If it is not written.it was not done

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• Key Components to encounters
• History
• Exam
• Medical Decision Making

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Basic Coding 101

• All three of the basic key components (Hx, Ex,
  MDM) are needed to be equal weight
• New patients
• Consults
• Hospital admits
• ED visits
• NH yearly physicals

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Basic Coding 101

• All three of the basic key components (Hx, Ex,
  MDM) are needed to be equal weight
• New patients
• Consults
• Hospital admits
• ED visits
• NH yearly physicals
• Only two of the three key components are needed
  to be equal
• Established patients not in those clinical
  situations above

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• Chief Complaint
• History of Present Illness
• Review of Systems
• Past, Family, or Social History

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• Chief Complaint
• Concise statement describing the symptom,
  problem, condition,etc. or other factor that is
  the reason for the encounter.
• CC back pain
• History of Present Illness
• Chronological description of the development of
  the patients presenting problems.
• Brief or Extended based on the amount of detail
  given in the record

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History of Present Illness

• Definitions
• Location- place, whereabouts
• Quality- description, characteristic to define
  chief complaint (CC)
• Severity- degree, intensity, ability to endure,
  1-10 scale
• Duration- length of time ongoing
• Timing- regulation of occurrence, when CC occurs
• Context- a circumstance or cause, outside
  factors
• Modifying factor- what makes it better/effects
  it, treatment plan adherance
• Associated features- other things that accompany
  or relate to the CC (ROS)

13
History of Present Illness

• Location-pain in left back
• Quality-throbbing pain in left back
• Severity-mild throbbing pain in left back
• Duration-mild throbbing pain in left back for two
  days
• Timing- mild throbbing pain in left back that was
  intermittent for two days but is more persistent
  today
• Context/Circumstances-and got worse when she
  picked up her 2 year old child.

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HPI (cont.)

• Modifying factors-mild throbbing pain in the left
  back for two days that was intermittent but is
  now more persistent today and got worse when she
  picked up her 2 year old child. Motrin has not
  helped.
• Associated Symptoms-.no rash, numbness in LE, or
  dysuria.
• Clinically Correct Coding (C3) Concept the
  associated symptoms is a natural transition
  into the review of systems and should be a part
  of every HPI.

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History Types

• Detailed (D)
• HPI 4 or more,
• 3 chronic prob.
• ROS 2-9 systems/body areas
• PFSH 1 element
• Comprehensive (C)
• HPI 4 or more,
• 3 chronic prob.
• ROS 10 or more
• PFSH 2 or 3 elements

• Problem Focused (PF)
• HPI 1-3 Elements
• Expanded Problem Focused (EPF)
• HPI 1-3 Elements
• ROS 1 Element
• (HPI/ROS inclusive)

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Clinically Correct Coding (C3) Concepts

• The basic history needs to contain FOUR of the
  HPI components to evaluate most problems
  encountered in primary care.
• Chronic problems justifiably can always have four
  HPI.

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HPI need 4

• Acute problems are easy
• Location low back pain
• Duration for 2 weeks
• Severity pain 4/10
• Modifying factors Motrin helps
• Chronic problems harder
• Location ???diabetes???
• Timing ??hypertension??

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HPI ALL patients (need 4)

• MY vote.DSMA
• Duration- years, months
• Severity-6/10, accelerated BP, EF 30, 4 cm AAA,
  60 carotid blockage, HbA1c 9.1
• Modifying factors- medication/dietary compliance
• Associated features- nausea, etc.
• Clinically Correct Coding (C3) Concept Starting
  out each HPI with DSMA will provide a uniformly
  appropriate history in both chronic and acute
  disease states.

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History Types

• Detailed (D)
• HPI 4 or more,
• 3 chronic prob.
• ROS 2-9 systems/body areas
• PFSH 1 element
• Comprehensive (C)
• HPI 4 or more,
• 3 chronic prob.
• ROS 10 or more
• PFSH 2 or 3 elements

• Problem Focused (PF)
• HPI 1-3 Elements
• Expanded Problem Focused (EPF)
• HPI 1-3 Elements
• ROS 1 Element
• (HPI/ROS inclusive)

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Review of Systems (1/system)

• Musculoskeletal
• Skin and/or breast
• Neurologic
• Psychiatric
• Endocrine
• Hematologic/lymph.
• Allergy/Immunologic

• Constitutional
• Eyes
• ENT, mouth
• CV
• Respiratory
• GI
• GU

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History Types

• Detailed (D)
• HPI 4 or more,
• 3 chronic prob.
• ROS 2-9 systems/body areas
• PFSH 1 element
• Comprehensive (C)
• HPI 4 or more,
• 3 chronic prob.
• ROS 10 or more
• PFSH 2 or 3 elements

• Problem Focused (PF)
• HPI 1-3 Elements
• Expanded Problem Focused (EPF)
• HPI 1-3 Elements
• ROS 1 Element
• (HPI/ROS inclusive)

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History Types

• Detailed (D)
• HPI 4 or more,
• 3 chronic prob.
• ROS 2-9 systems/body areas
• PFSH 1 element
• Comprehensive (C)
• HPI 4 or more,
• 3 chronic prob.
• ROS 10 or more
• PFSH 2 or 3 elements

• Problem Focused (PF)
• HPI 1-3 Elements
• Expanded Problem Focused (EPF)
• HPI 1-3 Elements
• ROS 1 Element
• (HPI/ROS inclusive)

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Past, Family, and Social History

• Past History
• Major illnesses, operations, medications,
  allergies, immunization status
• Family History
• Health status of relatives, diseases related to
  the problems addressed in the CC, hereditary risk
  factors
• Social History
• Use of tobacco, alcohol, drugs marital status,
  employment, living arrangements, education

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History Types

• Detailed (D)
• HPI 4 or more,
• 3 chronic prob.
• ROS 2-9 systems/body areas
• PFSH 1 element
• Comprehensive (C)
• HPI 4 or more,
• 3 chronic prob.
• ROS 10 or more
• PFSH 2 (estab.)
• or 3 elements (new)

• Problem Focused (PF)
• HPI 1-3 Elements
• Expanded Problem Focused (EPF)
• HPI 1-3 Elements
• ROS 1 Element
• (HPI/ROS inclusive)

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Past, Family, and Social History

• Past History
• Major illnesses, operations, medications,
  allergies, immunization status
• Family History
• Health status of relatives, diseases related to
  the problems addressed in the CC, hereditary risk
  factors
• Social History
• Use of tobacco, alcohol, drugs marital status,
  employment, living arrangements, education
• Clinically Correct Coding (C3) Concept
  assessing a patients medications/allergies OR
  tobacco use status clinically makes sense in all
  encounter types.

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C3 extras for history

• HPI and the ROS can be combined in the history
• Three chronic problems Detailed history
• PFSH obtained from an earlier encounter does not
  need to be recorded again, but it must be
  reviewed and noted
• No credit if not noted.
• ROS and PFSH may be taken by others.(not HPI ?)
• History can be obtained from someone other than
  the patient
• If ROS noncontributory, then need to document
  accordingly
• Not all other systems negative

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Clinically Correct Coding (C3) Concept Detailed
History Mnemonic 4 2 1

• From the History of Present Illness (HPI)
• obtain 4 elements (DSMA)
• From the Review of Systems (ROS)
• obtain 2 pertinent elements
• From the PFSH
• Obtain 1 element of the PFSH
• Can be done by nursing
• Remember nonsmoker and medication list ? count
  as two elements
• Equate to a Detailed History (4 2 1)
• 99214, 99203, 99283, 99221, 99218, 99243, and the
  99253 encounter
• C3 Concept The 4 2 1 history should be the
  initial building block for histories taken at
  every encounter.

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The detailed (4 2 1) history

• 65 yo for f/u HTN. Diagnosed in 4/2001.
  Checking BP at home with ranges 120-135/75-85,
  never over 140/90. Checks 2x/wk by daughter (RN).
  Following diet and exercise and is med
  compliant. No CP, visual probs, SOB, DOE, or LE
  edema. No rash or HA.

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The detailed (4 2 1) history

• 65 yo for f/u HTN. Diagnosed in 4/2001.
  Checking BP at home with ranges 120-135/75-85,
  never over 140/90. Checks 2x/wk by daughter (RN).
  Following diet and exercise and is med
  compliant. No CP, visual probs, SOB, DOE, or LE
  edema. No rash or HA.
• Meds Lisinopril 10mg/d, ECASA 81mg/d, HCTZ 12.5
  mg/d.

30
History Types

• Detailed (D)
• HPI 4 or more,
• 3 chronic prob.
• ROS 2-9 systems/body areas
• PFSH 1 element
• Comprehensive (C)
• HPI 4 or more,
• 3 chronic prob.
• ROS 10 or more
• PFSH 2 or 3 elements

• Problem Focused (PF)
• HPI 1-3 Elements
• Expanded Problem Focused (EPF)
• HPI 1-3 Elements
• ROS 1 Element
• (HPI/ROS inclusive)

31
History Types

• Detailed (D)
• HPI 4 or more,
• 3 chronic prob.
• ROS 2-9 systems/body areas
• PFSH 1 element
• Comprehensive (C)
• HPI 4 or more,
• 3 chronic prob.
• ROS 10 or more
• PFSH 2 or 3 elements

• Problem Focused (PF)
• HPI 1-3 Elements
• Expanded Problem Focused (EPF)
• HPI 1-3 Elements
• ROS 1 Element
• (HPI/ROS inclusive)

32
The Clinically Correct Coding (C3) Series
The Examination Key Component

• Nick Ulmer, MD CPC
• Principal ProTime, LLC
• VP Clinical Services and
• Medical Director of Case Management
• Spartanburg Regional Healthcare System

33
Basic E/M Objectives

• Be understanding of the key component of the
  history of an encounter and how it relates to
  correct coding (Session I)
• Know the mnemonics associated with the history
  and examination components and how they relate to
  correct documentation and coding of an encounter
  (Session II)
• Understand medical decision-making and how it
  relates to the clinically correct coding of an
  encounter (Session III)

34
Objectives for the Examination

• Understand the examination key component and how
  it relates to the clinical encounter
• Review this key component through the context of
  the 1995 and 1997 coding rules
• Know the mnemonics described to allow rapid
  recall of these components in clinically correct
  documentation of an encounter
• Link the mnemonics of the exam with those of the
  history key component

35
Objectives Examination

• Review the basics of 1995 and 1997 Guidelines
• Simplify the basics for data collection to equate
  to specific coding levels

36

• 1995 Guidelines Allows use of both a general
  multi-system exam or single organ system exam.
  No criteria for single organ system exam. With
  multi-system exam, content and performance
  elements are left to discretion of provider.
  Vagueness.

37
1995 Guidelines for Examination

• Body Areas
• Head, incl. face
• Neck
• Chest, breasts, axillae
• Abdomen
• Genitalia, buttocks
• Back
• Each extremity

• Organ Systems
• Constitutional
• Eyes
• ENT, mouth
• Cardiovascular
• Respiratory
• Gastrointestinal
• Genitourinary
• Musculoskeletal
• Skin
• Neurologic
• Psychiatric
• Hematologic/Lymph/Immunologic

38

• 1995 Guidelines
• Problem focused limited exam of affected area
  (1 body area examined)
• Expanded problem focused limited exam of
  affected body area/organ system and any other
  related organ system (2-7 areas)
• Detailed extended exam of affected body areas
  and any other related organ system (2-7 detailed
  areas)
• Comprehensive A general multi-system exam (or
  complete exam) of a single organ system and other
  complete related areas (8 detailed areas)
• C3 Concept Vagueness is a concern here

39

• 1997 Guidelines
• Exam types clearly defined by bullets.
• Any provider can use either type of exam
  (multi-system or single organ system).
• Most EMR systems set up on this as it is
  trackable. More defendable in audits.
• May use whichever benefits but not BOTH in an
  encounter

40

• 1997 Guidelines
• Problem Focused
• 1-5 Elements/bullets in 1 or more system
• Expanded Problem Focused
• 6 or more elements/bullets in 1 or more systems
• Detailed
• 12 or more elements/bullets in 2 or more systems
• Comprehensive
• 2 or more elements/bullets in 9 or more systems
  (touch all but document 18)

41

• 1997 Guidelines
• Problem Focused
• 1-5 Elements/bullets in 1 or more system
• Expanded Problem Focused
• 6 or more elements/bullets in 1 or more systems
• Detailed
• 12 or more elements/bullets in 2 or more systems
• Comprehensive
• 2 or more elements/bullets in 9 or more systems
  (touch all but document 18)
• Think.. 1 6 12 18

42

• 1997 Guidelines
• Review the General Multi-system Exam tool
• Vital signs 3 of 7
• One item in bullet counts (ears)
• CV is important 7 bullets!!!
• Abdomen is lacking
• Pay attention to the GU details..
• Make no bones about it with ortho
• Money without touching a patient
• skin (look), gait, psychiatric (4), appearance
  (1), others
• Remember 1,6,12,18

43
How do the exams compare?

• 1995
• PF 1 area examined
• EPF limited of affected area and a related area
• Detailed extended exam of one area and another
  related (2-7 areas)
• Comprehensive 8 detailed areas examined

• 1997
• PF 1 bullet
• EPF 6 bullets
• Detailed 12 bullets from two or more systems
• Comprehensive Complete exam, document 18 bullets
  from 9 systems

44
Single Organ System Exam

• More subspecialty oriented to allow more focus on
  subspecialists clinical areas of expertise
• Anyone can do the General Multisystem or Single
  Organ System
• Single System is a series of boxes, and varied
  numbers of elements selected from these boxes to
  allow a level of visit.
• Very confusing to most

45
Single Organ System Exam

• Cardiovascular
• Ear, Nose, and Throat
• Eye
• Genitourinary
• Hematologic/Lymphatic/Immunologic
• Musculoskeletal
• Neurological
• Psychiatric
• Respiratory
• Skin

46
C3 Concept Summary

• For ALL histories
• 4 2 1 Detailed (99203, 99214, 99221,
  99283)
• DSMA
• Duration Severity Modifying Factors
  Associated Features
• Associated Symptoms is bridge to ROS, so make it
  varied in its content to cover associated organ
  systems
• 2 ROS pertinent to CC
• 1 PFSH Medication list OR allergies OR smoking
  status
• For examination
• 1997 rules (bullet points) more defendable in
  audits
• 1 6 12 18 ? 12 is Detailed
• 1995 rules 2 well documented organ systems/areas
  (Detailed)
• Be clinically correct in the examination
  content and avoid include all buttons
• The Detailed history and exam often correlates
  with the level of medical decision making of
  primary care chronic disease management encounters

47
The Clinically Correct Coding (C3) Series
The Medical Decision Making Key
Component

• Nick Ulmer, MD CPC
• Principal ProTime, LLC
• VP Clinical Services and
• Medical Director of Case Management
• Spartanburg Regional Healthcare System

48
Medical Decision Making

• Review the building blocks for the key component
  of medical decision making
• Diagnoses
• Data
• Risk

49

• Why is it important?
• The only aspect of the three key components to
  withstand the test of time.
• Gaining an understanding of this will allow us to
  better code and charge patients for work done in
  an encounter

50

• What is it?
• it is not medical necessity
• it is the thought work
• what (we) went to school for
• our brain at work.put into words
• Cannot be found in an automated coding software
• Should be the component to determine a level of
  service (the charge) for the visit

51
What is Medical Decision Making?

• of Moderate nature?
• 99214, 99203, 99284, level 2 IP admission codes
• of High nature?
• 99215, 99205, 99285, level 3 IP admission codes

52
The Third Key Component

• History
• Examination
• Medical Decision Making
• Diagnoses managed (number and type)
• Data reviewed to manage diagnoses of visit
• Risk associated with the management plan

53
For MDM calculation on diagnosis

• Maximum point total is 4
• If 4 is maximum, then the maximum MDM is being
  met (High)
• If 3 is achieved, then moderate
• If 2 is achieved, then low
• If 1 is achieved, then minimal

54
Number of Diagnoses or Treatment Options Number of Diagnoses or Treatment Options Number of Diagnoses or Treatment Options Number of Diagnoses or Treatment Options
Types of Problems Number x points subtotal Number x points subtotal Number x points subtotal
Self limited, minor (max 2) 1
Est. problem, stable or improved 1
Est. problem, medical adjustment needed 2
New problem, no work-up planned 3
New problem, further work-up planned 4
Total Total Total
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TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) X High (4) X
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate X High X
element)
56
For MDM calculation on data

• Maximum point total is 4
• If 4 is maximum, then the maximum MDM is being
  met (High)
• If 3 is achieved, then moderate
• If 2 is achieved, then low
• If 1 is achieved, then minimal

57
Amount and Complexity of Data Reviewed Amount and Complexity of Data Reviewed
Categories of Data Reviewed Points
Order and/or review clinical lab tests (CPT 8xxxx series) 1
Order and/or review tests from radiology section (nuclear med., Xraynot echo/cath) (CPT 7xxxx series) 1
Order and/or review tests from medicine section (EKG,EMG,echo,dopplers,cath,PFT,audiometry,etc.) (CPT 9xxxx series) 1
Decision to obtain old records or decide to obtain history from other caregivers/family, or discuss tests with performing physician 1
Review and summarize old records by updating chart or taking history from someone other than patient (nurse at NH, interpreter, children) 2
Independent visualization of image, tracing, or specimen 2
Total
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TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
59
TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
60
TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
61
For MDM calculation on risk

• Highest box wins
• Moderate or High is our focus

62
RISK FACTORSSELECT HIGHEST IN CATEGORY RISK FACTORSSELECT HIGHEST IN CATEGORY RISK FACTORSSELECT HIGHEST IN CATEGORY RISK FACTORSSELECT HIGHEST IN CATEGORY
LEVEL OF RISK PRESENTING PROBLEM PROCEDURES ORDERED MANAGEMENT OPTIONS CHOSEN
Minimal One self-limited or minor prob. Labs, X-rays, EKG, EEG Rest, superficial dressings
Low Many self-limited or minor 1 chronic stable illness Acute, uncomplicated illness/injury Physiologic test w/o stress Imaging studies w/ contrast Superficial needle biopsy Skin biopsy Arterial blood draw OTC meds Minor surgery w/o risk factors Physical/Occupation Therapy IVF w/o additive
Moderate One or more chronic illnesses with exacerbation, progression, or treatment of side effects 2 or more chronic stable illnesses New prob w/ uncertain prognosis Acute illness with systemic symptoms Acute complicated injury Stress test Endoscopies w/o risk factors CV imaging w/o risk factors Deep needle biopsy Centesis of body cavity Minor surgery w/ risk factors Elective major surgery w/o risk factors Prescription drug management IVF w/ additives Closed Rx of skeletal injury
High 1 or more chronic illness with SEVERE exacerbation, progression, or treatment side effects Acute/chronic illness that may pose threat to life or bodily f(x) Sudden neurologic change CV imaging studies with risk factors Cardiac EPS tests Endoscopy with risk factors Discography Elective major surgery with risk factors Emergency major surgery IV controlled drug Drug therapy requiring intensive monitoring DNR status
63
TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
64
TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
65
TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
66
TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
67
TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS TABULATION OF DECISION MAKING ELEMENTS
A Diagnoses/Management Options Minimal (0-1) Low (2) Moderate (3) High (4)
B Amount/Complexity of Data Min./Low (0-1) Low (2) Moderate (3) High (4)
C Highest Risk (from any category in table) Minimal Low Moderate High
Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Medical Decision Making (Choose the column with at least 2 elements. Otherwise, pick the middle column of the three columns with 1 element) Straight-forward Low Moderate High
element)
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Moderate (Detailed)Medical Decision Making (MDM)

• IF you manage a prescription, AND
• There are three chronic, stable problems OR
• There are two chronic problems, 1 in need of
  medical management OR
• There is one new problem, with no further work-up
  planned
• THEN, there is MODERATE MDM

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High (Comprehensive)Medical Decision Making (MDM)

• IF you manage a patient with three medical
  conditions and one is out of control
• OR
• You manage two medical conditions and both are
  out of control
• OR
• You manage a new problem and other diagnostics
  (CT, MRI, etc.) are needed to fully care for the
  patient
• AND
• The illness(s) are such as severe respiratory
  distress, progressive severe RA, acute kidney
  injury, suicidal gesture/threats, seizure, TIA,
  sudden weakness, or acute MS change
• THEN
• That decision making falls in line with HIGH MDM

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Thanks

• Nick Ulmer, MD CPC
• 864-684-4248 (cell/text)
• NUlmer_at_ProTimeLLC.com