APPLICATION MEDICAL DECISION MAKING RULES TO SEIZURE DISORDERS



E/M TEMPLATE: Level 4 Inpatient Consultation (99254)

A consult is a request for advice by a qualified health care provider. It is not a request for transfer of care.

Necessary to bill for level 4 visit:

Moderate complexity medical decision making (MDM) PLUS

Comprehensive history and comprehensive examination

MEDICAL DECISION MAKING (MDM) RULES

Moderate MDM when 2 of the following (from 3 categories) achieve 3 points each:

1. Multiple Numbers of diagnosis or management options

Two problems inadequately controlled (2 points each)

New symptom not requiring further workup (3 points)

Three problems whether stable, improved, or not (3 points)

2. Moderate 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. Moderate Risk of morbidity and mortality (3 points)

Writing of a prescription drug

IV fluids with additives

Lumbar puncture

Discography

Incisional nerve/muscle biopsy

Examples: Manage Rx drug for a patient with 1 new symptom not requiring evaluation/treatment

Manage Rx drug for a patient with 1 inadequately controlled problem, plus 1 problem stable or improved

Manage Rx drug for a patient with 3 problems stable

If counseling and/or coordination of care consumes > 50 % of the encounter with the patient and /or family, then bill for level 4 inpatient consultation if the face to fact time plus unit and floor time is more than 40 minutes of an 80 minute consultation. The neurologist must document the actual face-to-face and unit and floor 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 |

---AND---

Comprehensive 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) |Coordination (1) |

|(Maximum of 1 point) | |

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

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

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