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1 1 Stephanie is LION (Linked In Open Network)
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5 9 The 3 Key Components 1. History History of Present Illness (HPI) Review of Systems (ROS) Past, Family and Social History (PFS) 2. Exam 3. Medical Decision Making Number of Diagnoses and Treatment Options Amount and Complexity of Data Overall Risk Time may be used if the total time is documented and more than 50% of the encounter is spent in counseling or coordination of care 10 5
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7 HPI: location quality severity timing context mod factor duration asso. S&S ROS: constit eyes ENMT cardio respir GI GU MS skin neuro psych endo hemat/lymph allerg/immuno PFSH: past family social New Out Pt LEVEL Type (x) PF 1 2 Est Pt LEVEL (x) EPF D or2+ (Est.) C 4 & Number of Body Areas/Systems Examined Typ e New Out Pt LEVEL (x) Est. Out Patient LEVEL (x) 1 PF limited EPF extended (4x4) D (Systems only) C 4 &
8 - Minor =1 each (max 2) - Est. stable/improved = 1 each - Est. worsening =2 each - New problem, w/o workup =3 each (max 1) - New problem, w workup=4 each Example Type Minimal: 1 point as totaled from above Limited: 2 points as totaled from above Multiple: 3 points as totaled from above Extensive: 4 + points as totaled from above Uncomplicated, noninfected insect bite Controlled HTN and tachycardia New patient with migraine headaches Patient seen today for f/u on OA knees and 1 year THR check. C/O knee pain. MRI ordered for possible meniscus tear. R/O symptom of osteoarthritis and sprain New or Established Outpatient LEVEL Straightforward 1 & 2 Low Moderate High One Point Each: Clinical Labs test(s) ordered and/or reviewed CPT Medicine Section Test(s)- ordered and/or reviewed CPT Radiology Section Test(s)- ordered and/or reviewed Discuss patient results with performing/consulting Dr. Decision to obtain old records or add hx from other than pt Two Points Each: Review & sum data from old records add hx from other than pt (2nd) interpretation of an image, tracing, specimen Minimal: 1 point as totaled from above Limited: 2 points as totaled from above Moderate: 3 points as totaled from above Extensive: 4 + points as totaled from above Type New or Established Outpatient LEVEL Straight-forward 1 & 2 Low 3 Moderate 4 High 5 8
9 CMS TABLE OF RISK Overall Risk between planned encounters Any example listed from a row below for any of the three columns will equal a level of risk. 1. Presenting Problem(s) 2. Diagnostic Procedure(s) Ordered 3. Management Options Selected Type New or Established Outpatient LEVEL One self-limited or minor problem, eg cold, insect bite, tinea corporis Laboratory tests requiring venipuncture Chest x-rays EKG/EEG Urinalysis Ultrasound, eg, echocardiography KOH prep Rest Gargles Elastic bandages Superficial dressings Minimal 1 & 2 Two or more self-limited or minor problems One stable chronic illness, eg, well controlled hypertension or non-insulin dependent diabetes, cataract, BPH Acute uncomplicated illness or injury, eg, cystitis, allergic rhinitis, simple sprain Physiologic tests not under stress, eg, pulmonary function tests Non-cardiovascular imaging studies with contrast, eg, barium enema Superficial needle biopsies Clinical laboratory tests requiring arterial puncture Skin biopsies Over-the-counter drugs Minor surgery with no identified risk factors Physical therapy Occupational therapy IV fluids without additives Low 3 One or more chronic illnesses with mild exacerbation, progression, or side effects of treatment Two or more stable chronic illnesses Undiagnosed new problem with uncertain prognosis, eg, lump in breast Acute illness with systemic symptoms, eg, pyclonephritis, pneumonitis, colitis Acute complicated injury, eg, head injury with brief loss of consciousness Physiologic tests under stress, eg, cardiac stress test, fetal contraction stress test Diagnostic endoscopies with no identified risk factors Deep needle or incisional biopsy Cardiovascular imaging studies with contrast and no identified risk factors, eg arteriogram, cardiac catheterization Obtain fluid from body cavity, eg, lumbar puncture, thoracentesis, culdocentesis Minor surgery with identified risk factors Elective major surgery (open, percutaneous or endoscopic) with no identified risk factors Prescription drug management Therapeutic nuclear medicine IV fluids with additives Closed treatment of fracture or dislocation without manipulation Moderate 4 One or more chronic illnesses with severe exacerbation, progression, or side effects of treatment Acute or chronic illnesses or injuries that pose a threat to life or bodily function, eg multiple trauma, acute MI, pulmonary embolus, severe respiratory distress, progressive severe rheumatoid arthritis, psychiatric illness with potential threat to self or others, peritonitis, acute renal failure An abrupt change in neurologic status, eg, seizure, TIA, weakness, or sensory loss Cardiovascular imaging studies with contrast with identified risk factors Cardiac electrophysiological tests Diagnostic Endoscopies with identified risk factors Discography Elective major surgery (open, percutaneous or endoscopic) with identified risk factors Emergency major surgery (open, percutaneous or endoscopic) Parenteral controlled substances Drug therapy requiring intensive monitoring for toxicity Decision not to resuscitate or to de-escalate care because of poor prognosis High
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17 Start: A medically necessary, separately billable, evaluation and management service. Dr. is treating (or Tx is impacted by all diagnoses counted) Pt Pt risk of life or Actively Yes limb between now & Yes 5 sick or injured? next encounter? No No 3 or 4 Pt w/ stable or inactive Condition/s? Yes More than 1 problem? Yes More than 3 problems? Yes 4 or 5 No No No 2 or 3 3 or 4 Pt w/ minor or self limited problem/s? Yes More than 1 problem? Yes More than 2 problems? Yes 2 or 3 No No No 1 or 2 2 or 3 Preventive Medicine *This chart should only be used for the purpose of guiding discussion: it references new outpatient visits
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24 47 80% of those in pre-med will not be accepted to medical school Medical school Under-Grad Medical School Residency Fellowship License to Practice 48 24
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