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Medical Decision Making – Your Assessment & Plan. The critical service you provide The key driver to your reimbursement. Learning Objectives. Importance for patient care Billing rules Documentation priorities while in the room Finishing your notes Practice for this week.
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Medical Decision Making –Your Assessment & Plan The critical service you provide The key driver to your reimbursement
Learning Objectives • Importance for patient care • Billing rules • Documentation priorities while in the room • Finishing your notes • Practice for this week
Importance of MDM for Patient Care • It is what patients value from their doctor • It is why most of us went to medical school • It is what we want need to review when we see the patient the next time • It is what our coverage looks for when they do a chart biopsy • It is what the jury considers when deciding whether we acted reasonably, i.e. it is our malpractice defense!
Billing rules that shape your documentation • In order to bill a given level of Medical Decision Making you must meet two of three criteria. The criteria are: • Problems • Data analysis • Risk
Priorities in the room • Diagnoses – You can leave them “naked” • Orders • Medications – easiest using RxWriter • Immunizations • Labs • Future Nurse Orders • Follow Up with cause • Instructions
Finishing your note • Most efficiently done if you can complete before you do your chart biopsy for your next patient • If you can’t, <Show Doc, Ctrl T> to save temporary copy • Edit/complete S: &O: • “Clothe” your naked diagnoses with comments that speak to items in Presenting Problem column of Risk • If “naked” they are minor and/or self-limited • Stable chronic or uncomplicated (then you can add) • Uncontrolled chronic or new with risk(s) • End organ damage, threat to life, abrupt neuro change
Finishing your note - Plan • Edit/Complete Orders not recorded in room • Add management options that don’t rise to the level of Orders • Add Counseling/Coordination of Care • Add you FTT name and CPT code • Show Doc & Print
Practice for this week • Enter your diagnoses while in exam or preceptor room before patient leaves. • Document all your orders before the patient leaves. • Write all your prescriptions using ezSOAP. • Focus preceptor feedback on the O: and P: portions of the note. • The final three lessons will be putting these skills together in specific kinds of visits.
