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UCSF Clinical Enterprise Compliance Program CECP Education Series Wanda T. Ziemba MFA RHIT CHCO CHCC CHC CPC Associate Compliance Officer & Clinical Enterprise Compliance Program Educator
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Our Last Cruise … June 19 – Cruising Down the Alimentary Canal – Already Traversed July 17 – Beauty Is Skin Deep – Been There, Done That August 21 – Getting to Know the Ship’s Doctor
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If you see this doctor, you’re on the wrong Enterprise …
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Third “Port” of Call: The Ship Doctor and E&Ms Medical Decision Making –Type of Problem –Data –Risk History of Present Illness –HPI –ROS –PFSHx Physical Examination –1995 and 1997 guidelines
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Medical Decision Making Chief Complaint Type of Problem –Self-Limited, Minor, 1pt (Max 2) –Est, Improved, Stable, 1pt –Est, Worsening, 2pts –New, No W/Up or Plan, 3 pts –New, W/Up & Plan, 4 pts
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Medical Decision Making (cont.) Amount/Type of Data –Rev/Order Clinical Labs, 1 pt (max 1) –Rev/Order Imaging Studies, 1 pt (max 1) –Rev/Order Medical Diagnostics, 1 pt (max 1) –Discuss to Obtain Old Records, 1 pt –Discuss Results w/performing MD, 1 pt –Rev/Summ Old Records, 2 pts –Independent Rev, Tracing, Image, 2 pts
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Medical Decision Making (cont.) Risk Table –Minimal/Minor –Low –Moderate –High Time Dominated –Total time/Counseling Time
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Bingo #1: MDM New onset sexually transmitted disease, likely chlamydia Zithromax prescribed 500mg QD x 3 days Send for range of motion study under x-ray, right shoulder Refer to Cardiology for evaluation Total time: 30 minutes, 20 minutes of which was spent discussing safe sex while on cruise ships
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And the winner is … Type of Problem: New, w/up & plan (4 pts) Amount/Type of Data: 1 pt Risk: moderate Equals: Moderate MDM
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History HPI –Location – Modifying Factors –Quality – Timing –Severity – Context –Duration – Associated signs/symptoms
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History (cont.) Review of Systems –Constitutional –Eye –ENMT –Cardiac –Respiratory –GI –Musculoskeletal –Integ/Breast –Neuro –Psych –Endocrine –Heme/Lymph –Allergy/Immunologic
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History (cont.) PFSHx –Past Medical History –Family History –Social History
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History: What Level? Focused –CC –HPI: 1-3 Expanded –CC –HPI: 1-3 –ROS: 1 pertinent Detailed –CC –HPI: 4+ –ROS: 2-9 –PFSHx: 1 Comprehensive –CC –HPI: 4+ –ROS: 10+ –PFSHx: 2-3 (3-=N,C)
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Bingo #2: History 25 m dilated & hypertrophic CM w/ mild MR, hyperthyroidism Concerns re: STDs; contact 1 wk ago, irritation, burning on urination, OTC tinactin, no Δ No D/C, partner x 1 w/yeast infx, Ǿ IVD/Tattoos – energy level Ǿ Δ Ǿ CP, Ǿ CHF Sx’s, Ǿ palps ↑weight 5 lbs
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Did you win? CCHPIROSPFSHxLevel Genital irritation Duration; context; assoc. s&s; modifying factors Constitutional; cardiovascular Partner w/yeast infx; Dilated & hypertrophic CM; mild MR; hyperthyroidism 4 HPI2 ROS2 PFSHxDetailed
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Physical Examination 1995 and 1997 –Focused 97: 1-5 elements 95: 1 BA/OS –Expanded 97: 6 elements 95: 2-7 BA/OS –Detailed 97: 2 bullets for 6 BA or 12 bullets in 2 or more BA 95: 2-7 BA/OS Detailed –Comprehensive: 97: All elements 95: 8+ OS
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Bingo #3: PE The patient is a 25 year old white male, alert & orient x 3, cooperative and in NAD. VS: 110/70, 60, 5’9”, 179 lbs AT NC PERRLA EOMI Neck Ǿ LAD Ǿ TM PMI ND S1 S2 (↑ A2) HS nml apex CTAB no retractions R shoulder notable >> larger L shoulder? Ǿ C/C/E nml pulse + foreskin, Ф irritation Ф discharge Ǿ no mass test Ф hernia
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Who won this time? BA/OS19951997Comment Cons12 GA & VS (when at least 3) Eye11 Pupils & iris Head1 Under MS in 1997 guidelines ENMT11 TM CV14 Auscultation, palpation, edema, pulses Resp12 Auscultation & effort Ext2 Not in 1997 guidelines MS3 Inspection/palpation 3 areas Lymph11 Cervical GU13 Penis, testicles, hernia Psych12 Mood & affect, orientation Neuro11 EOMI – Cranial nerves
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What’s the overall code? MDM: Moderate History: Detailed PE: Comprehensive Time: 30 minutes (if using time) 99203
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Questions?
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