When we do get into the medical decision making, there are components, the management options, the amount of the data and the level or risk. In the management options, they have self-limited or minor problems, established and worsening problems. And then there's the new problem and then the new problem with additional workup. Know more with these tips provided by our evaluation and management coding training expert in a healthcare conference.
If we did see maybe we saw this patient and the physician said that ‘I need you to go for an x-ray and then come back and we'll talk about the results’. That would have been a new problem with additional workup as opposed to what actually happened in this. And that was that it was just a new problem.
And what is defined as new, it's new to the examiner, not to the patient. So the patient obviously has had this piece of glass in her thumb for an extended period of time. So it's established for her, it's worsening for her. But it's new to the physician who is seeing this problem for the first time.
Amount and complexity of the data, we have labs, x-rays, we have services that are found in the medicine section, EKGs, EEGs, sleep studies and the like. We have the discussion of the tests with the performing physician, actually looking at the specific tests and films, getting old records, reading old records, getting history from somebody other than the patient.
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If you have the patient and let's just say her husband. And the husband gives you information that the patient wasn’t very forthcoming with. If you indicate that you obtained this information from the husband, the rest of the information from the patient, you're able to give credit appropriately under the medical decision making because you did gain history from somebody other than the patient. That somebody could also include another physician, children, the patient, a caregiver, a caseworker and those kinds of people.
Our expert mentioned in the healthcare conference that if you do review old records and you want credit for it under the medical decision making; you also have to summarize those old records. So that's an important component to make certain that that's included in the medical decision making.
We do want to point out to coders and to auditors that that component is often at the beginning of the note that might be in the history where the physician is summarizing the old record up to the date that the patient walked in to see us for this particular problem.
So again, just because it's in the latter part of the auditing tools used, that doesn’t necessarily mean that you wouldn't get the information from anywhere within the body of the note.
This is just a sample from the table or risk. There is minimal, low, moderate and high. Looking at this, we see a moderate visit is an undiagnosed new problem with uncertain prognosis, maybe a chronic illness with a mild exacerbation. In this instance, it was acute uncomplicated problem, stated our healthcare training expert in a healthcare conference.
High or extensive would get you up to your level five services if ever all the other documentation was there and medically appropriate. But that’s for life threatening illnesses.
So again, you want to make certain that you're looking clearly at the documentation, the patient’s co morbidities when you're looking at the level of risk in assigning that service.
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