Medical Decision Making What we all went to medical school to do! Bryan L. Goddard, M.D. August 2010

Starting with the end in mind Why we are starting with MDM instead of H&P Assessments are more than ICD codes Treatments that aren’t structured 2

MDM defines what History and PE counts and is required History unrelated to MDM is ROS and rarely changes billable service PE findings are countable only if needed by MDM, e.g. 7 pt. Musculoskeletal exam for hypertension not warranted! History that results in orders, but is not documented, is “money left on the table!” In Family Medicine, counseling and/or coordination of care drives billing in 1/3 of visits 3

Getting everything in By requiring diagnoses to write orders, eCW “forces” you to add diagnoses to support orders Make sure the Principal diagnosis has X on it, even if not the top because you nurse ordered symptom- driven labs or immunizations, e.g. Patient requested pregnancy test due to late period at visit for headaches. If >4 diagnoses, make sure the ones that affect the billing are in the top four lines. 4

Making sure your Problem Points count 5

Avoid Naked Diagnoses! A “naked diagnosis” is a diagnosis without thinking behind it. Educationally, clothing your diagnoses will help you remember what you learned through discussion with preceptor Patient care will benefit if patient is seen by your coverage or after you’ve forgotten what you were thinking Billing is enhanced when you describe the Risk and/or interaction with other diagnoses 6

Where to put the “clothes” Specify – This is a good place for brief comments like “New,” “Controlled,” “At target,” “Terminal,” etc. that speak to MDM points Notes – Since these are assigned by diagnosis, this area is ideal for “analysis” i.e. differential diagnosis, thoughts about likelihood, reasons why not controlled, etc. The patient will not see these notes. Free text field at bottom – This follows the entire list and is a good place for “synthesis,” i.e. when you put things together, e.g. DJD of knee, diabetes out of control, & back pain all related to morbid obesity. 7

Creating your Assessment Comments in eCW 8

What the final note looks like 9

Treatments Structured orders – lab, DI, procedures, & referrals drive most of the points of MDM Text fields on Treatment screen print on Visit Summary, so keep it understandable by patient (alternatives: enter in assessment or after printing Visit Summary) Synthesis counseling can be documented under Others Counseling/Coordination of Care (that drive 1/3 of billing!) can be documented in the Notes field at bottom – preferably on Other Tab when there are multiple assessments 10

Tools to help document MDM in eCW 11

12 ←Progress Note Visit Summary ↑

Preceptor documentation of supervision Once you have documented your MDM, your preceptor should be able to document his/her supervision Print DI orders for Black Out-Guides Hyperlinks will be in note for them to use to document approval of referrals. 13