Application Medical Decision Making Rules to Seizure Disorders s1

E/M TEMPLATE: Level 2 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 2 visit:

Straight forward medical decision making PLUS

Expanded Problem Focused history AND Expanded Problem Focused examination

MEDICAL DECISION MAKING (MDM) RULES

Straight Forward MDM when 2 of the following (from 3 categories) achieve 1 point each:

1. Limited Number of diagnosis or management options- 1 point

Established problem (to examiner), stable, improved, or

Self-limited or minor problem (stable, improved or worsening)

2. Limited Complexity of data reviewed- 1 point

Review lab reports (1)*, or order labs (1)*, or order diagnostic testing (1)*

*If lab/tests are ordered and results are obtained during the same visit, 1 point total is given

3. Minimal Risk of morbidity and mortality (1 point)

Order lab test requiring venipuncture, or urinalysis

Chest X-ray

ECG/EEG

Ultrasound

Examples: Order a lab study on a patient with a stable or improved problem

If counseling and/or coordination of care consumes > 50 % of the encounter with the patient and /or family, then bill for level 2 new patient visit if the face-to-face time is time is more than 10 minutes of a 20 minute evaluation; and more than 15 minutes of a 30 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.

Problem Focused History

History of Present Illness

/ Chief complaint, plus 1-3 points regarding location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms
Review of Systems / Problem pertinent, one system
Past, Family, Social History / None needed

---AND---

Single System Neurologic Examination (6 to 11 of 25 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) ( 1 point maximum) / Coordination (1)
Mental Status (5) / Sensation (1)
Cranial Nerves (8) / Gait (1)