APPLICATION MEDICAL DECISION MAKING RULES TO …



E/M TEMPLATE: Level 4 Consultation or New Patient

A new patient is someone not evaluated in the past 3 years by any member of a physician group of the same specialty. A consult is a request for advice by a qualified health care provider: not a request for transfer of care.

Necessary to bill for level 4 visit:

Moderate complexity medical decision making 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

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 new patient visit if the face-to-face time is more than 23 minutes of a 45 minute evaluation; and more than 31 minutes of an 60 minute consultation. 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 |

---AND---

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) |Coordination (1) |

|(Maximum of 1 point) | |

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

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

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