1. The critical service you provide The key driver to your reimbursement

2. Learning Objectives Importance for patient care Billing rules Documentation priorities while in the room Finishing your notes Practice for this week

3. Importance of MDM for Patient Care It is what patients value from their doctor It is why most of us went to medical school It is what we want need to review when we see the patient the next time It is what our coverage looks for when they do a chart biopsy It is what the jury considers when deciding whether we acted reasonably, i.e. it is our malpractice defense!

4. Billing rules that shape your documentation In order to bill a given level of Medical Decision Making you must meet two of three criteria. The criteria are: Problems Data analysis Risk

5. Problems Problems/Differential DiagnosesPoints Self-limited or Minor (maximum of 2)1 Established problem(s), stable, controlled, or at target1 Established problem(s), worsening, uncontrolled, or not at target2 New problem, no additional work-up planned3 New problem, additional work-up planned4

6. Data Data ReviewedPoints Review/order clinical lab tests1 Review/order diagnostic images (X-rays, CT, MR, ultrasound, nuclear)1 Review/order other diagnostic tests (ECG, echo, PFTs, etc.)1 Discussion of results with performing physician1 Independent review of image, tracing, or specimen2 Order old records1 Review & summary of old records2

7. Risk Presenting ProbsDx ProceduresMgmt Options Minimal1 self-limited (SL) or minor Labs, images, or med test Rest, non-pharm, & superficial Low 2+ SL or minor 1 stable chronic 1 acute uncomp Non-stress tests Contrast image ABG or skin bx OTCs Minor surg PT/OT, Ivs Moderate 1 unctrl chronic 2 ctrl chronic 1 new w/ risk Cardiac stress Cardiac imaging Rx management IVs with additives High 1+ chronic w/ new end organ damage Threat to life or bodily function Abrupt change in neurologic status Cardiac contrast studies for sx Cardiac EP studies Endoscopic studies Parenteral controlled drugs Drug therapy w/ toxicity monitoring Palliative Care

8. Putting it together Best two out of three! MDM Complexity ProblemsDataRisk Straight Forward11Minimal Low Complexity22Low Mod. Complexity33Moderate High Complexity44High

9. Priorities in the room Diagnoses – You can leave them “naked” Orders Medications – easiest using RxWriter Immunizations Labs Future Nurse Orders Follow Up with cause Instructions

10. Finishing your note Most efficiently done if you can complete before you do your chart biopsy for your next patient If you can’t, to save temporary copy Edit/complete S: &O: “Clothe” your naked diagnoses with comments that speak to items in Presenting Problem column of Risk If “naked” they are minor and/or self-limited Stable chronic or uncomplicated (then you can add) Uncontrolled chronic or new with risk(s) End organ damage, threat to life, abrupt neuro change

11. Finishing your note - Plan Edit/Complete Orders not recorded in room Add management options that don’t rise to the level of Orders Add Counseling/Coordination of Care Add you FTT name and CPT code Show Doc & Print

12. Practice for this week Enter your diagnoses while in exam or preceptor room before patient leaves. Document all your orders before the patient leaves. Write all your prescriptions using ezSOAP. Focus preceptor feedback on the O: and P: portions of the note. The final three lessons will be putting these skills together in specific kinds of visits.