Medical Decision Making

1. Medical Decision Making What we all went to medical school to do! Bryan L. Goddard, M.D. August 2010

2. Starting with the end in mind • Why we are starting with MDM instead of H&P • Assessments are more than ICD codes • Treatments that aren’t structured

3. MDM defines what History and PE counts and is required • History unrelated to MDM is ROS and rarely changes billable service • PE findings are countable only if needed by MDM, e.g. 7 pt. Musculoskeletal exam for hypertension not warranted! • History that results in orders, but is not documented, is “money left on the table!” • In Family Medicine, counseling and/or coordination of care drives billing in 1/3 of visits

4. Getting everything in • By requiring diagnoses to write orders, eCW “forces” you to add diagnoses to support orders • Make sure the Principal diagnosis has X on it, even if not the top because you nurse ordered symptom-driven labs or immunizations, e.g. Patient requested pregnancy test due to late period at visit for headaches. • If >4 diagnoses, make sure the ones that affect the billing are in the top four lines.

5. Making sure your Problem Points count

6. Avoid Naked Diagnoses! • A “naked diagnosis” is a diagnosis without thinking behind it. • Educationally, clothing your diagnoses will help you remember what you learned through discussion with preceptor • Patient care will benefit if patient is seen by your coverage or after you’ve forgotten what you were thinking • Billing is enhanced when you describe the Risk and/or interaction with other diagnoses

7. Where to put the “clothes” • Specify – This is a good place for brief comments like “New,” “Controlled,” “At target,” “Terminal,” etc. that speak to MDM points • Notes – Since these are assigned by diagnosis, this area is ideal for “analysis” i.e. differential diagnosis, thoughts about likelihood, reasons why not controlled, etc. The patient will not see these notes. • Free text field at bottom – This follows the entire list and is a good place for “synthesis,” i.e. when you put things together, e.g. DJD of knee, diabetes out of control, & back pain all related to morbid obesity.

8. Creating your Assessment Comments in eCW

9. What the final note looks like

10. Treatments • Structured orders – lab, DI, procedures, & referrals drive most of the points of MDM • Text fields on Treatment screen print on Visit Summary, so keep it understandable by patient (alternatives: enter in assessment or after printing Visit Summary) • Synthesis counseling can be documented under Others • Counseling/Coordination of Care (that drive 1/3 of billing!) can be documented in the Notes field at bottom – preferably on Other Tab when there are multiple assessments

11. Tools to help document MDM in eCW

12. ←Progress Note Visit Summary ↑

13. Preceptor documentation of supervision • Once you have documented your MDM, your preceptor should be able to document his/her supervision • Print DI orders for Black Out-Guides • Hyperlinks will be in note for them to use to document approval of referrals.