Application Medical Decision Making Rules to Seizure Disorders

E/M TEMPLATE: Level 3 Consultation or New Patient

A new patient is someone not evaluated in the past 3 years by any member of a physician group of the same specialty. A consult is a request for advice by a qualified health care provider: not a request for transfer of care.

Necessary to bill for level 3 visit:

Low complexity medical decision making PLUS

A detailed history AND detailed examination

MEDICAL DECISION MAKING (MDM) RULES

Low complexity MDM when 2 of the following (from 3 categories) achieve 2 points each:

1. Limited Number of diagnosis or management options

One problem inadequately controlled (2 points)

New symptom not requiring assessment or treatment (3 points)

Two problems stable or improved (2 points)

2. Limited Complexity of data reviewed (2 points)

Review and/or order of clinical lab tests (CBC, Urinanalysis, etc.) (1), review and/or order radiology tests (1), review and/or order EEG, EMG, EKG, Hearing test, spirometry, sleep study, etc. (1), discuss test results with performing physician (1), independent review of imaging, tracing, or specimens (i.e. review of slides, raw data, EEG tracings) (2), decision to obtain old records and/or obtain history from others (1), review/summarize old records and/or obtain history from others and/or discussion with other healthcare provider (2)

3. Low Risk of morbidity and mortality (2 points)

Over the counter drugs

Physical Therapy

Occupational Therapy

IV fluids without additives

Examples: Recommend OT/PT or OTC RX for a patient with 1 new symptom not requiring evaluation/treatment

Recommend OT/PT or OTC RX for a patient with 1 inadequately controlled problem

Recommend OT/PT or OTC Rx for a patient with 2 problems stable or improved

If counseling and/or coordination of care consumes > 50 % of the encounter with the patient and /or family, then bill for level 3 new patient visit if the face-to-face time is time is more than 16 minutes of a 30 minute evaluation; and more than 21 minutes of a 40 minute consultation. The neurologist must document the actual face-to-face time and a brief summary of the topics discussed. This can be used in place of the bulleted HX-PX-MDM system.

Detailed History

History of Present Illness

/ Chief complaint, plus 4 or more points regarding location, quality, severity, duration, timing, context, modifying factors, associated signs and symptoms
Review of Systems / 2-9 systems reviewed
Past, Family, Social History / 1 point of past, family, or social history

---AND---

Single System Neurologic Examination (12 of 23 points)

General Appearance (1) / Tone (1)
3 or more vital signs (1) / Strength (1)
Fundus (1) / Reflexes (1)
Cardiovascular Examination - pulses, bruits, or auscultation of heart (1) ( 1 point maximum) / Coordination (1)
Mental Status (5) / Sensation (1)
Cranial Nerves (8) / Gait (1)