APPLICATION MEDICAL DECISION MAKING RULES TO …



E/M TEMPLATE: Level 5 Established Patient

Necessary to bill for level 5 visit:

High complexity medical decision making PLUS

A comprehensive history or examination

MEDICAL DECISION MAKING (MDM) RULES

High Complexity MDM when 2 of the following (from 3 categories) achieve 4 points:

1. Extensive Number of Diagnosis or Management Options

Two problems inadequately controlled (2 points each)

New symptom requiring further work-up (4 points)

2. Extensive Complexity of Data Reviewed

Review and/or order of clinical lab tests (CBC, Urinanalysis, etc.) (1), review and/or order radiology tests (1), review and/or order EEG, EMG, EKG, Hearing test, spirometry, sleep study, etc. (1), discuss test results with performing physician (1), independent review of imaging, tracing, or specimens (i.e. review of slides, raw data, EEG tracings) (2), decision to obtain old records and/or obtain history from others (1), review/summarize old records and/or obtain history from others and/or discussion with other healthcare provider (2)

3. High Risk of Morbidity and Mortality (4 points)

Chronic illness with severe exacerbation, progression, or adverse effect from treatment or that poses a threat to life or body function

An abrupt change in neurologic status (seizure, TIA, stroke, weakness, sensory loss)

Drug therapy requiring intensive monitoring for toxicity, e.g., coumadin, immunosuppressant, AEDs

Management of 4 RX drugs

Examples: A patient with 1 new symptom needing evaluation/treatment

A patient with 2 inadequately controlled problems (weakness, sensory change, bladder, bowel)

If counseling and/or coordination of care consumes > 50 % of the encounter with patient and /or family, then bill for level 5 established patient visit if the face-to-face time is more than 21 minutes of an 40 minute evaluation. The neurologist must document the actual face-to-face time and a brief summary of the topics discussed. This can be used in place of the bulleted HX-PX-MDM system.

Comprehensive History

|History of Present Illness |Chief complaint, plus 4 or more points regarding location, quality, severity, duration, timing, |

| |context, modifying factors, associated sign and symptoms |

|Review of Systems |Complete (10 or more systems) |

|Past, Family, Social History |Complete, 1 point each for past, family, social history |

---OR---

Single System Neurologic Examination (23 of 23 points)

|General Appearance (1) |Tone (1) |

|3 or more vital signs (1) |Strength (1) |

|Fundus (1) |Reflexes (1) |

|Cardiovascular Examination - pulses, bruits, or auscultation of heart (1) ( 1 |Coordination (1) |

|point maximum) | |

|Mental Status (5) |Sensation (1) |

|Cranial Nerves (8) |Gait (1) |

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