Power of the Pen. Iyad G. Houshan. M.D. Assistant Professor of Medicine Chief, Division of Hospital Medicine University of Nevada School of Medicine. ICD-9 codes. 40 y.o. male with PMHx of 250.4, 272.4, 496, here for 491.21 exacerbation and possible 410. How do you treat this patient?
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Iyad G. Houshan. M.D.
Assistant Professor of Medicine
Chief, Division of Hospital Medicine
University of Nevada School of Medicine
( an inpatient hospital admission), or a 5 (Outpatient or consultations).
3) medical decision making MDM
Medicare will not pay for anything unless “Medical Necessity” is met
Medical Necessity is not clinical at all it is financial term
High: “Severe” exacerbation of chronic illness. Acute illness threatening life or lim, Abrupt change in neurological status, Ordering of CV angiography, endoscopy with risk factors, pt needs emergent major surgery, Parenteral controlled substances, DNR decision.
Moderate: mild exacerbation, progression, 2 or more stable chronic illnesses, acute illness with systemic symptoms ( pyelonephritis, colitis,..), ordering of stress test, ednoscopy without risk factors, needle biopsy; pt needs elective major surgery, prescription drug management, IV fluids with additives
Review, order lab……………..1 point
Review, order Radiology……..1 Point
Other tests……………………..1 Point
Obtaining old records…………1 Point
Review and summary
of old records………………….2 Points
Indep. Interpretation of test….1 Point
Discussion of unexpected
result with interp doctor………1 Point
MAX POINTS = 4
# of new or chronic self limiting
problems…………………Max 2 points
improved, well controlled #_X1=
Inadequate control, worsening #_X2 =
New problem no work up……3 points
New problem with work up planned.. 4 points
OF THE TWO HIGHEST
( new patient visits)
3 of 3 categories=complete
● ROS= 1 problem pertinent
-Chest, including -CVS
Breast and axilla -G.I.
Detailed or comprehensive history and exam, low complexity MDM
Comprehensive history and exam, Moderate complexity MDM
Comprehensive history and exam, High complexity MDM
And Afib. ( being treated, on coumadin)
D o c u m e n t a t i o n
“ If you did not document it, it did not happen”
Problem focused History ( 1-3 elements, No ROS, No PFSH required).
Problem focused Exam ( body area related to problem).
MDM straightforward or low complexity
Expanded problem focused History ( 1-3 elements, 1 ROS, No PFSH required)
Expanded Problem focused Exam ( 2-4 systems).
MDM moderate complexity
Detailed History ( 4 or more elements, 2-9 ROS, 1PFSH).
Detailed Exam ( 5-7 systems).
MDM high complexity.