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MEDICAL DECISION-MAKING: Content of Service
Transcript of MEDICAL DECISION-MAKING: Content of Service
Presenting problem that is not known to the physician (New) that DOES require diagnostic workup.
Presenting problem that is not familiar to the performing physician, and that does not require diagnostic
Presenting problem that is known to the physician (established) and worsening.
Presenting problem that is known to the physician (established) and stable or improving.
PROBLEM with WORKUP
...the condition, disease, illness, injury, complaint or other medical reason for which the patient has presented to the healthcare facility for the E/M service.
...specific tests used to determine the internal function, status, structures, and/or
pathology occurring within
Management Options Selected
Review of Diagnostic Test Results
Independent Visualization of Image, Tracing, or Scan
Ordering Diagnostic Data
Obtain Old Records
Obtain Additional History
of Diagnostic Results with Physician
who Performed Diagnostic
AMOUNT of DATA to be REVIEWED
COMPLEXITY of DATA to be REVIEWED
LEVEL of RISK
...documentation of any existing or initiated method of treatment, care, or management of the presenting problem.
All material taken from
MEDICAL CODING EVALUATION AND MANAGEMENT,
Kate Gabriel-Jones; Larry A. Bohn, Pearson 2014