#Em client review 2014 driver#
#Em client review 2014 code#

A total of four points is associated with high complexity medical decision-making. Although a point system for quantifying the diagnoses and management options associated with patients' health problems is not an official part of the E/M documentation guidelines, many Medicare contractors use a point system for educational and auditing purposes. THE ELEMENTS OF MEDICAL DECISION-MAKING Type of decision-makingĪt least two of the three criteria – problem(s), data, risk – must be met or exceeded. (See “ The elements of medical decision-making.”)

#Em client review 2014 code#

Typically, risk is used as one of the defining criteria however, any two of the subsections could be used as the basis for code selection. Two of the three subsections (problem, data, or risk) are needed for determining the level of medical decision-making. High complexity medical decision-making is associated with a 99215 visit. These help determine the level of medical complexity from minimal complexity to high complexity. Medical decision-making is also the most complex of the three key components of the documentation guidelines, having three subsections: problem points, data points, and risk. We urge you to routinely make medical decision-making one of the two key components used for deciding if the patient's care is worthy of the 99215 code. However, if the patient does not require medications, testing, or even a bandage for the hangnail, it is doubtful that the high level of care provided was medically necessary. For example, a physician may treat a patient for a hangnail and perform a comprehensive history and physical examination in the process, detailing every inch of the patient's history and performing an exam of his or her entire body.

#Em client review 2014 driver#

Medical decision-making should be the primary driver for code selection. (For more information, read “ Exam Documentation: Charting Within the Guidelines,” FPM, May/June 2010.) The 1995 guidelines are vague by comparison and may create trouble if your definition of the exam does not coincide with the definitions used by the auditor, so we recommend using the more specific 1997 guidelines. The 1997 guidelines are quite specific and rely on documentation of individual bullets, which makes it easier to support the level of service submitted. A common way of remembering the exam documentation requirements for each level of exam is to build from a problem-focused visit to a comprehensive visit using the “rule of sixes.” (See “ Rule of sixes for general multisystem physical exam documentation.”) Coding 99215 requires a comprehensive exam in which two elements in each of nine or more organ systems and body areas are documented. For instance, four exam elements define the “Respiratory” portion of the general multisystem exam: assessment of respiratory effort, percussion of the chest, palpation of the chest, and auscultation of the lungs. This article focuses on the 1997 version of the E/M guidelines, which lists 14 organ systems and body areas comprising the general multisystem exam.

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