Preparation: Medical Decision Making .

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Goals. Comprehend the way of E/M servicesUnderstand the relationship between ICD-9-CM and E/M codesUnderstand the relationship between restorative need and E/M codesBe ready to characterize E/M servicesUnderstand the components and levels of medicinal choice makingBe ready to decide the level of therapeutic choice making for an E/M experience.
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Preparation: Medical Decision Making Date: 25 March 2010 Time: 0800–0850

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Objectives Understand the way of E/M administrations Understand the relationship between ICD-9-CM and E/M codes Understand the relationship between medicinal need and E/M codes Be ready to characterize E/M administrations Understand the components and levels of restorative basic leadership Be ready to decide the level of therapeutic basic leadership for an E/M experience

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Overview Nature of E/M Services Evaluation and Management Defined Medical Decision-Making Diagnoses as well as Management Options Data Reviewed/Ordered Level of Risk of Complications or potentially Morbidity or Mortality

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Nature of E/M Services: ICD-9 and CPT Coding Relationship ICD-9 codes clarify WHY the administration was performed CPT codes clarify WHAT administration was performed Diagnosis codes must support the CPT code(s) alloted

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Nature of E/M Service: Medical Necessity Medical need – Patient\'s exhibiting issue or explanation behind the visit Level of administration gave is reliant upon what is therapeutically sensible and fundamental as showed in the documentation , not only the measure of documentation Supported by ICD-9 analyze codes allocated

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Nature of E/M Service: Evaluation and Management Defined The expert administrations gave eye to eye by supplier amid a Visit: Healthcare portrayed by the expert examination or potentially assessment of a patient and the conveyance or solution of a care regimen. For a visit to be tallied, there must be: Interaction between an approved patient and a human services supplier, Independent judgment about the patient\'s care, and Documentation (counting, at the very least, the date, center name, explanation behind visit, quiet evaluation, portrayal of the collaboration between the patient and the social insurance supplier, manner, and mark of the supplier of care) in the patient\'s approved record of restorative treatment. ( DoD 6010.15-M)

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E/M Components E/M Components History* Examination* Medical Decision-Making* Counseling Coordination of Care Nature of Presenting Problem Time * = Key Component

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Medical Decision-Making: CMS and CPT Description Refers to the multifaceted nature of setting up a determination as well as choosing an administration alternative, which is dictated by considering the accompanying components: The quantity of conceivable conclusions and additionally the quantity of administration choices that must be viewed as (Box A); The sum or potentially intricacy of therapeutic records, symptomatic tests, and additionally other data that must be acquired, looked into and investigated (Box B); and The danger of noteworthy entanglements, dreariness, as well as mortality and additionally co-morbidities related with the patient\'s displaying problem(s), the analytic procedure(s), as well as the conceivable administration choices (Box C).

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Medical Decision-Making 3 Elements: Number of conclusions/administration choices Amount of information checked on/requested Level of danger of difficulties and additionally bleakness or mortality 4 Levels: Straightforward Low Moderate High To meet all requirements for a given sort of basic leadership, two of the three components must be met or surpassed

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Medical Decision-Making: Diagnoses as well as Management Options Primary Diagnosis: MHS Guidelines 2.2.1: The essential analysis is the explanation behind the experience, as dictated by the documentation. The central grumbling does not need to coordinate the essential analysis. AMA CPT 2010 pg. 7: "An infection, condition, ailment, harm, manifestation, sign, discovering, protestation, or other explanation behind experience, with or without a finding being set up at the season of the experience." Secondary Diagnoses: MHS Coding Guidelines 2.2.2: Conditions or maladies that exist at the season of the experience, yet don\'t influence the ebb and flow experience are not coded. Archived conditions or infections that influence the present experience, are considered in basic leadership, and are dealt with or surveyed, are coded. AMA CPT 2010 pg. 10: "Co-morbidities/fundamental illnesses, all by themselves, are not considered in choosing a level of E/M administrations unless their nearness essentially expands the multifaceted nature of the restorative basic leadership."

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Diagnosis Code Selection Must be upheld by documentation in the present note Specific as could be expected under the circumstances (e.g., pneumonia versus strep pneumonia) Include keenness of determination (e.g., intense, serious, interminable, mellow, direct, and so on.) May be taken from conclusive evaluation or boss protest Use signs/manifestations if not able to make complete finding amid experience Cannot code analysis portrayed as "discount… plausible... conceivable… sketchy… " Also code auxiliary conditions influencing treatment 11

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Medical Decision-Making: Diagnoses and additionally Management Options

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Example: Diagnoses as well as Management Options A/P: 1) Joint agony, likely optional to joint inflammation, headstrong to OTC torment meds; 2) HTN; 3) Obesity – no change from last visit; 3) Elevated trigs. Rx 10 day course prednisone for joint agony; diminish abstain from food/increment work out.

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Medical Decision-Making: Diagnoses or potentially Management Options

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Example: Diagnoses and additionally Management Options A/P: 1) URI, settling, likely popular; steady care; 2) HTN.

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Medical Decision-Making: Diagnoses and additionally Management Options

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Data Reviewed or Ordered

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Example: Data Reviewed or Ordered Order CBC, UA, Chem 7, CXR

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Data Reviewed or Ordered

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Example: Data Reviewed or Ordered EKG: NSR w/some ectopy Order resound, CXR, labs Reviewed Santa Rosa Cardiology TTE 7/09 and 10/09. 7/09 TTE indicates gentle/direct mitral disgorging; 10/09 TTE demonstrates same + slight pneumonic valve stenosis.

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Data Reviewed or Ordered

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Level of Risk 22

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Example: Level of Risk A/P: Chest divider torment – likely costochondritis . EKG typical; plan treadmill. Rx OTC NSAIDs, restrain exercises that compound uneasiness. Come back to Dr. Brinkley for progressing care.

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Level of Risk

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Example: Level of Risk A/P: HTN (controlled): Continue exhibit administration atenolol Chronic cerebral pains (serious), arrange EEG w/o photon design; counsel to Neuro Obesity – Counseled pt to begin slim down/practice program w/steady progression,stressing significance of getting more fit to enhance BP RTC 1 month to audit EEG, Neuro counsel

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Example: Level of Risk

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Leveling Medical Decision-Making – Box D

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Leveling Medical Decision-Making – Box D

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Leveling Medical Decision-Making – Box D

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Leveling Overall Leveling

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Reminder… "If it\'s not archived; it wasn\'t finished." NOT BILLABLE

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References Medicare Learning Network "Assessment and Management Services Guide", July 2009 CPT® 2010 Professional Edition, American Medical Association

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Q&A Questions?

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