APPLICATION MEDICAL DECISION MAKING RULES TO SEIZURE DISORDERS



E/M TEMPLATE: Level 5 Inpatient Consultation (99255)

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 a level 5 visit:

High complexity medical decision making (MDM) PLUS

A comprehensive history AND comprehensive examination

MEDICAL DECISION MAKING (MDM) RULES

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

1. Extensive Number of diagnoses or management options

Two problems inadequately controlled (2 points each)

New problem requiring further work-up (4)

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 for any of the situations below)

Chronic illness with severe exacerbation, progression, or adverse effect from treatment

An abrupt change in neurologic status (seizure, TIA, stroke, weakness, sensory loss, AMS changes, marked worsening of degenerative disease)

Drug therapy requiring intensive monitoring for toxicity (4 points), e.g., coumadin, immunosuppressants, some AEDs, black box drugs

Illnesses that pose a threat to life or body function

Examples: A patient with 1 new symptom/or complaint needing additional workup (with labs, imaging and EMG, EEG, spirometry, NBT/NPT)

A patient with 2 inadequately controlled problems (weakness, sensory change, bladder, bowel, or non-neurologic disorder)

A patient with a sudden abrupt change in neurologic status (TIA weakness) or known epileptic with breakthrough seizures and LOC. Or patient with late effect of stroke with speech/cognitive/motor problems

Falls in Parkinsonian patients; MS patient with inadequately controlled complications

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 55 minutes of an 110 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, and 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 point |Coordination (1) |

|maximum) | |

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

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

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