ࡱ> CEBq` bjbjqPqP 42::J|||  fff8\ "":\\\\\\prrrrrr$hS\\\\\\\   \.\\p \p   \ UsVf. D,0 GRG G $\\ \\\\\ \\\\\\\ f f MEDICAL DECISION MAKING Determine this level first, then verify that chart documentation (HPI, ROS, PFSH & Examination) supports the level. Bold areas are what are commonly managed in SBHCs. Use the following chart. If 2 or 3 are in the same level, choose that level. If only 1 is selected in each level, choose the middle level. New99201*99202992039920499205Established9921199212992139921499215Diagnoses or Management Problems-One Self-limited or minor problem-Two or more self-limited or minor problems -One stable chronic condition -Acute uncomplicated illness (e.g., allergic rhinitis, simple sprain-One or more chronic illnesses with complications -Two or more stable chronic illnesses -Undiagnosed new prob. w/ uncertain prognosis -Acute illness with systemic symptoms -Acute complicated injury-One or more chronic illness with severe complications -Acute or chronic illness or injury that is life or limb threatening -Abrupt change in neurologic statusDiagnostic Procedures (only 2 areas must agree to determine medical decision making level, so this area is not usually the deal breaker as most SBHC do not typically do level 3, 4 or 5 Diagnostics)-Lab -X-ray -EKG -UA -Ultrasound -Venipuncture -KOH.-Physiologic tests not under stress -Pulmonary Function -Barium enema -Arterial puncture -Skin biopsies-Physiologic tests under stress - cardiac stress test -Diagnostic endoscopies with no risk factors -Deep needle or incisional biopsy -Obtained fluid from body -Cardiovascular imaging w/ contrast-Cardiovascular imaging with contrast Invasive diagnostic tests -Cardiac electrophysiological tests -Diagnostic endoscopies w/ identified risk factors -DiscographyTreatment of Management Options-Rest -Gargles -Elastic bandages -Dressings-OTCs -Minor surgery w/ no identified risk factors -PT -OT -IVs without additives-Minor surgery with risk factors -Elective major surgery - no risk factors -Prescription drug management -IV fluids with additives -Closed fracture or dislocation treatment w/o manipulation -Therapeutic nuclear medicine-Elective surgery with identified risk factors -Emergency major surgery -Parenteral controlled substances -Drug treatment w/ intense monitoring -Decisions not to resuscitate or de-escalate d/t poor prognosis * For a new patient 99201, use the requirements for a new patient 99202     PAGE 1  FILENAME TOT Coding Handout 1 - Blank Coding Audit Cheat Sheet This form shall forevermore be knows as: The Dianne Demers Coding Compliance Cheat Sheet -  PAGE 1 - S T v w   4 9 x   $ Źvӫvevevv h]/hYDCJOJQJ^JaJ#h]/hYD5CJOJQJ^JaJhYD5CJOJQJ^JaJ'jhYD0JCJOJQJU^JaJhYDCJOJQJ^JaJhYDCJOJQJ^JhYDCJOJQJ^JaJhYDCJOJQJ^JaJhYD5CJOJQJ^JaJhYD5CJOJQJ^JaJ'NT X _ e k q x $$If]a$gdYD $$Ifa$gdYD $IfgdYD^gdYD`gdYDgdYD Ex y <3'' $$Ifa$gdYD $IfgdYDkd$$Iflֈb HP!|)T8p t0n(4 laz $$If]a$gdYD $$Ifa$gdYD  <3333 $IfgdYDkd$$Iflֈb HP!|)T8p t0n(4 laz 3 x % ? v $If]gdYD $IfgdYD <3333 $IfgdYDkd$$Ifl ֈbx 5!|)T t0n(4 laz   # 6 E { .Hl  $If]gdYD $IfgdYD<3333 $IfgdYDkd$$Ifl ֈbx 5!|)T t0n(4 laz-15Lm (Wp $If]gdYD $IfgdYDCEFHIKLNOQRXYZ[\^_`jk޿޹{sgsgZhYDOJQJmHnHujhYDOJQJUhYDOJQJ!hYDCJOJQJaJmHnHuh.DhYDCJOJQJaJ%jh.DhYDCJOJQJUaJhYD0JmHnHu hYD0JjhYD0JUjhYDUhYD5OJQJh !hYDhYDCJOJQJ^JaJhYD5CJOJQJ^JaJ#CD<7570gdYDgdYDkd$$Ifl ֈbx 5!|)T t0n(4 lazDEGHJKMNPQ\]^_  &`#$  h !hYDhYDOJQJjhYDOJQJU2&P:pYD/ =!"#$% $$Ifz!vh5T58555p5#vT#v8#v#v#vp#v:V l t0n(5T58555p54az$$Ifz!vh5T58555p5#vT#v8#v#v#vp#v:V l t0n(5T58555p54az$$Ifz!vh5T55555#vT#v#v#v#v#v:V l t0n(5T555554az$$Ifz!vh5T55555#vT#v#v#v#v#v:V l t0n(5T555554az$$Ifz!vh5T55555#vT#v#v#v#v#v:V l t0n(5T555554az8`8 YDNormal_HmH sH tH DA@D Default Paragraph FontRi@R  Table Normal4 l4a (k@(No List4 `4 YDFooter  !.)`. 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