Surgeons as Educators A Guide for Academic Development and Teaching Excellence

429

and risk (not to be confused with Deutsche Democratic Republic). Assuming pillars
1 and 2 meet level 5 criteria then:

Diagnoses level 5, data level 3, risk level 5 – Bill level 5
Diagnoses level 5, data level 4, risk level 3 – Bill level 4
Diagnoses level 5, data level 3, risk level 3 – Bill level 3

Pillar 3a: Diagnoses (And/or Management Options)
The more diagnoses you address and mark as being considered allows for higher
billing. A level 2 visit is a “minimal” diagnosis: a self-limited or minor problem or
one established problem. A level 3 visit is a “limited” diagnosis – this can fall into
four different scenarios: two self-limited minor problems, two established prob-
lems, one established problem worsening, or one stable chronic illness. A level 4
visit is a “multiple” diagnosis – this can fall into three different scenarios: one new
problem with no additional work-up planned, three established problems, or two
established problems one of which is worsening. Finally, a level 5 visit is an exten-
sive diagnosis  – this also has three possibilities: four established problems, two
established problems both worsening, and a new problem with further work-up
planned. Dizzying I know but really, you only have to remember two things here:

1. If the patient presents with a new problem that you have to work up or do some-
   thing about (order a lab or X-ray, etc.), you get level 5 instantly – not too tough.


2. Add one billing level to the number of established problems you are treating. If
   a patient has many problems (remember you have to address these not just arbi-
   trarily list them), it is again very simple to get to the highest level.

MEDICAL DECISION MAKING

2 out of 3 must be met or exceeded for a given level of decision making

Number of Dx/Mgrnt Options Amt. And/or Complexity

of Data to be Reviewed Risk of Complications and/orMorbidity or Mortality

Nature of Presenting Problems

Diagnostic Procedares Ordered

Management Options Selected

Use Table of Risk

1 point Order and/or reviewclinical lab tests

rediology tests incl.nuclear med. & all other

imaging except echoand cardiac cath

1 point Discussion of test resultswith performing physician

2 points Direct visualization andindependent review of an

image, speciman or tracing

2 points

Point system

Extensiv(4 points)e

Multiple(3 points)

Limite(2 points)d

Minima(1 point)l 1 self limitedor minor problem

2 self limited/minor problems2 est. problems

1 est. problem, worsening1stable chronic illness

1 new problem w/o add’l wu planned3 est. problems

2 est. problems; 1 worsening

4 est. problems2 est. problems, worsening

1 new problem w/ add’l wu planned

1 = minimal

2 = limited

3 = multiple/moderate

2

3

4

Levels

Review and summationof old records and/or obtaining

history from someone other

Decision to obtain old recordor to obtain history from someones

other then the patient Highest Lecategory detervel of Risk in anmines the overaly onel

level of risk mortality/morbidity

Amt. of Risk

Minimal

Low

Moderate

High

2

3

4

5

Levels

Fig. 23.4 Medical decision-making rules

23 Evaluation and Management Documentation, Billing, and Coding