1. Evaluation & Management, Teaching Physician Guidelines & Pain Management Documentation

19. Medical Decision Making 06/11/11 Number of Diagnoses and Treatment Options Pts Total Self limiting or minor problems (stable, improved, or worsening) Maximum of 2 points 1 Established Problem – Stable Improved 1 Established Problem - Worsening 2 New Problem – No Additional Work-up Planned Maximum of 1 problem given credit 3 New Problem – Additional Work-up Planned 4 Total Points

20. Medical Decision Making cont. 06/11/11 Amount and Complexity of Data Pts Total Ordered and/or reviewed clinical lab 1 Ordered and/or reviewed radiology 1 Ordered/reviewed test in Medicine Section, CPT 1 Discussed tests with performing/interpreting Doc 1 Independent visualization and direct view of image, tracing, specimen 2 Decision to obtain old records/additional HX from someone other than patient (family, caretaker, previous physician) 1 Reviewed and summarized old records and/or obtained history from someone other than patient 2 Total Points

21. Medical Decision Making cont. Table of Risk 06/11/11 Level Presenting Problem Diagnostic Procedure Management Options Straight-forward One self limited or minor problem, ie: cold, insect bite, tinea coporis Lab test requiring venipuncture, chest x-ray, EKG/Eeg, Urinalysis, Ultrasound, KOH prep Rest Gargles Elastic Bandages Superficial Dressing Low Two or more self limited or minor problems One stable chronic illness Acute uncomplicated illness Non-cardiovascular imaging study w/contrast Superficial needle biopsy Clinical laboratory test requiring arterial puncture Skin biopsy Over the counter drugs Minor surgery w/no identified risk factors Physical therapy Occupational therapy IV fluids without addititives Moderate One or more chronic illnesses with mild exacerbation, progression or side effect of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis Acute illness with systemic symptoms Physiological tests under stress Diagnostic endoscopies w/no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging study w/contrast & no identified risk factor Obtain fluid from body cavity Minor surgery w/identified risk factor Elective major surgery w/no identified risk factor Prescription drug management Therapeutic nuclear medicine IV fluids w/additives Closed treatment of fracture or dislocation w/o manipulation High One or more chronic illnesses w/severe exacerbation, progression or side effect of treatment Acute or chronic illness or injuries that pose a threat to life or bodily function An abrupt change in neurological status Cardiovascular imaging studies w/contrast w/identified risk factor Cardiac electrophysiological tests Diagnostic endoscopies w/identified risk factors Discography Elective major surgery w/identified risk factor Emergency major surgery Parenteral control substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis

23. Tallying Level of Service New Patient/Consultations 06/11/11 HISTORY EPF Detailed C C EXAM EPF Detailed C C COMPLEXITY OF MEDICAL DECISION Straight Forward Low Moderate High Initial 99202 99242 99252 99203 99243 99253 99204 99244 99254 99205 99245 99255

24. Tallying Level of Service Established Out Pt/Subsequent Consult 06/11/11 If a column has 2 or 3 circles, draw a line down the column and circle the code OR draw a line down the column with the center circle and circle the code HISTORY PF interval EPF D C EXAMINATION PF EPF D C COMPLEXITY OF MEDICAL DECISION SF L M H Subsequent 99212 99213 99214 99215

46. Questions and Answers 06/11/11