Risk and Medical Decision Making

Shared Medical Decision Making
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enter site Medicare discovered that auditors were having a hard time nailing down the level of Medical Decision-Making during the medical review process. In point of fact, this is the way your Medical Decision-Making will be graded in the event of an audit. New problem, with no additional work-up planned maximum of 1. The above table is fairly self explanatory.


For example, consider a patient with diabetes who is being evaluated by a vascular surgeon for a lower extremity revascularization procedure. This is because the comorbidity of diabetes does significantly influence the risk of the procedure and the complexity of the post operative management. Even if the problem was previously known to other physicians or to the patient, it is still considered new to you if you are seeing the patient for the first time. This situation arises often in the case on consultations.

The progress notes of Michel Accad, MD

Practice Management Observation versus inpatient status Publish date: September 17, Perceived social risk was highest for children in the lowest SES categories but differed by minority status. This is discussed in BBR Chapter Please help to establish notability by citing reliable secondary sources that are independent of the topic and provide significant coverage of it beyond a mere trivial mention. Robert L.

Data Reviewed. Review or order clinical lab tests.

Review or order radiology test except heart catheterization or echo. Discuss test with performing physician. Independent review of image, tracing, or specimen.

4.2 Involving Patients and Health Care Professionals in benefit risk decision-making

Decision to obtain old records. Review and summation of old records.

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For example, if you review lab results and order labs during the same visit, you only get one point not one point for ordering and one point for reviewing. Commonly overlooked points are those garnered for obtaining or reviewing old records. If you do review old records, you must summarize your findings in the chart.

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You can still claim these points, even if the image, tracing or specimen has been reviewed by another physician as when a radiologist provides an official interpretation for an X-ray. The following table lists the criteria and scoring system:. Note that you receive only one point for all the data you review in any one category.

If you ordered or reviewed three different lab tests, for instance, you can claim only one point. But if you ordered or reviewed a lab test, an X-ray and an EKG, you receive a total of three points, which supports a moderate level of complexity for this component.

Medical decision making for E/M services

You also can claim points for discussing test results with the physician who performed the test or for obtaining history from an old medical record or from another source, such as a language interpreter. And you can add two points for reviewing or summarizing an old medical record and for an independent visualization of an image, tracing or specimen. Once you choose that level of complexity, you can turn to the other two elements.

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Be sure, however, that you meet or exceed the point scores for that same complexity level to claim that level of complexity for the entire service. You would need to score at least three points or more in either the diagnosis and management options or the amount and complexity level of decision-making for the entire service.

One final point: Always remember to document the thought processes you use to arrive at a diagnosis or management plan. Many physicians fail to note the routine tests they order or the many factors they take into account.

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Kristy Welker is an independent medical coding consultant based in San Diego. E-mail your documentation and coding questions to her at kristywelker hotmail. Wednesday, September 25, Today's Hospitalist. Home Coding Choosing the right level of complexity in medical decision-making. Steer clear of copy and paste. Waxing nostalgic. Recent articles.

Original Research ARTICLE

Medical decision making Em coding. E/M Coding and Risk is determined by referring to the table of risk which describes four levels of medical jeopardy. Medical decision-making (MDM) mistakes are common. Patient risk is categorized as minimal, low, moderate, or high based on pre-assigned items pertaining.

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