All right, so this segue, so we talked about problem addressed, which is the first column to decision-making, data. Now we're going to talk about the risk of complications. So the overall risk of morbidity, complications, and we are going to provide you with clinical examples. All right, so this is kind of that gray area. You have to paint the risk, the overall risk of that patient, and if it's vague, what happens, the payer, the auditor may make that decision for you. We don't want that. We want you to make that decision. Again, it's your decision-making, it's your level, it's your workup of that patient. So again, risk, that's that third column to medical decision-making. So what are we going to talk about? We're going to just dive through the entire risk table. We're going to talk about medical decision-making with risk examples. I want to spend some time on endoscopic risk, because that is so, so important in your documentation, and then we're going to end it with some medical decision-making tips and questions. All right, we've got another question for you, and I'm picking your brain again. So question, if a patient is being seen in follow-up for GERD and the provider documents continue PPI therapy in the plan of care, do they receive credit for moderate risk for prescription drug management? Yes, because PPI medications can be given in the form of a prescription. No, the provider must document the name and dosage of the prescription. You tell me, I have no clue, or it depends on the mood of the auditor or the coder looking at your note. All right, so 26% of you said yes, because PPI medication can be given. In the form of a prescription, no, the provider must document. That's 61%, that is correct. All right, and I'm going to talk a little bit about that later on. We're just going to table that. Glad to see that 61% response, and we see this a lot. We see just continue this medication. It's like, tell me, what are they on? Are you writing a prescription? What's the dosage? When do they take it, et cetera? Those details should be in your impression and plan of care. All right, so let's talk about that risk table. And, you know, it says, one element used in selecting the level of service is the risk of complication, anorbidity, or mortality of patient management at the encounter. Okay, so it says the risk, the probability and or consequences of an event. The assessment of the level of risk is affected by the nature of the event under consideration. For example, a low probability of death may be high risk, whereas a high chance of a minor self-limited adverse effect of treatment may be low risk. So definitions of risk are based upon the usual behavior and thought process of the provider in the same specialty. Trained clinicians apply common language usage meaning to terms such as high, medium, low, or minimal risk and do not require quantification. You don't have to explain your thought process. They're basically saying, you're the provider. If you tell me that the patient is high risk for something, then we give you credit for that. For the purpose of medical decision making, level of risk is based upon consequences of the problem addressed at the encounter when appropriately treated. Risk also includes decision making related to the need to initiate or forego further testing, treatment, or hospitalization. The risk of patient management criteria applies to the patient management decisions made by the reporting provider at that encounter. We're going to talk about social determinants of health. I know Kathy had mentioned this in the updates. Okay, there are a lot of diagnosis codes that can relay that social determinant of health. That is a column to your risk category. And we'll talk a little bit more about that as we move on. We also still have the drug therapy requiring intensive monitoring for toxicity. So, this is a drug that requires your monitoring that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of the adverse effects and not primarily for assessment of therapeutic surgery. Okay, minor or major, elective, emergency, patient or procedure risk. So, what is considered minor or major? It says the classification of surgery into minor or major is based on the common meaning of such term when used by you as the provider. When you use that term, risk, and what are the risks? These terms are not defined by surgical package classifications. And the thing is here, whenever they first came out with the E&M guidelines for the office, they gave us all these new categories for surgery. And I'm looking at, okay, minor surgery, major surgery. What does that mean? And, you know, Kathy can tell you, too. Kathy and me, we were all bound, like, what does this mean? And so, we thought it did mean the surgical package. So, if it's a minor procedure, it would be anything that has like a zero or 10-day global package to it. If it's a major surgery or major procedure, it has more of a 90-day global. That's kind of what we thought. Well, they redefined it, and they said, nope, it's up to the provider to document whether it's minor or major. If you don't say, guess what the assumption is? Probably minor. Again, unless you're saying, you know, transfer the patient to the hospital, they need to have an emergency appendectomy. All right, then they also talk about what's elective. What's an elective surgery? What's an emergency surgery? Elective procedures and emergent or urgent are described by the timing of the procedure when it's related to the patient's condition. So, obviously, if it's an elective, you're planning it, you're scheduling it out. But an emergent procedure is immediate or with minimal delay to allow for patient stabilization. But both elective and emergent procedures may be minor or major. Let's talk a little bit about risk factors, and this is patient or procedure risks. Risks are those that are relevant to the patient and procedure. Evidence-based risk calculators may be used, but they're not required. So, again, another breakdown of the decision-making table, and this is the table of risk. That's the third column to decision-making. And the thing is, we don't, they don't give you very many, they don't give you any examples of straightforward and low. It just says straightforward is minimal risk of morbidity from additional diagnostic testing or treatment. Low risk is the same. Low risk of morbidity from additional diagnostic testing or treatment. How about moderate? Okay, they give us some examples here for moderate. Prescription drug management, minor surgery with identified, okay. Now, diagnostic endoscopy is considered minor unless you tell me it's major for that patient. Elective major surgery without identified risk factors. And then, again, they added a new one to the risk. Diagnosis or treatment significantly limited by social determinants of health. High risk, again, we get some examples here. Drug therapy requiring intensive monitoring for toxicity. Decision for major surgery with identified risk factors. Emergency major surgery, a decision not to resuscitate or deescalate care because of the prognosis of the patient. New added decision for hospitalization. All right, so what does this mean? For straightforward risk, so again, back to your level 2, 99202212 for risk. Minimal risk of morbidity. So this could be, if you're recommending follow up as needed, or you're discharging the patient from your care, or I threw this in here, go home and go to bed. That's minimal risk. What about low risk? Over the counter medications, physical therapy, occupational therapy, nutritional diet or dietary counseling, minor surgery, and or diagnostic studies without risk factors. Hmm, so a lot of our patients could actually fall into the low risk category. If you're seeing a patient, they come in, they're relatively healthy. They're just having some GI issues. You're going to do an endoscopic workup on that patient. They have no risk factors, or you don't tell me they have risk factors. That's low risk. Moderate risk. Again, prescription drug management, minor surgery, elective major with no risk factors, diagnosis or treatment significantly limited by social determinants of health. So let's look at prescription drug management. Adding, refilling, increasing, decreasing, and discontinuing a prescription medication. A lot of you may not, you may not have been aware that even just refilling a medication counts as prescription drug management, but I cannot stress this enough, and that's that next bullet. Make sure you document the name, dosage, frequency, and the assessment and plan of care. A notation of continue medications does not support management. Continue medications, what does that mean? Continue your home medications, continue your medications your primary care had you on, or my, the medication that I am managing for you, okay? So important, and I, we see this a lot when we're, when we're doing audits, and we're looking at documentation. GERD, continue PPI medication, I'm not going to give you credit for prescription drug management. GERD, refill the patient's Nexium, this dose, et cetera. That's prescription drug management. Now, I am going to make a comment. Some payers do not count, give you credit for prescription drug management if you just say, go get it renewed, okay? Keep that in mind, but most of them do. Medicare specifically says any of those, adding, refilling, increasing, decreasing, discontinuing, all of those, but please be sure you document it. Document the name, dosage, frequency. Another area for moderate, decision regarding minor surgery with identified risk factors. So if you document endoscopic workup with identified risk factors in the assessment and plan of care, that is moderate risk. So I'm going to get a colonoscopy on this patient, this patient is at increased risk because of their COPD, their coronary artery disease, whatever it is, document it. How about decision regarding an elective major surgery without risk factors? So it could be a bowel resection on a patient with ulcerative colitis that has no risk factors, okay? Most of the time those patients are probably going to be in the hospital, but again, if you're recommending that, you're working that up, you get credit for moderate risk. Diagnosis or treatment significantly limited by social determinants of health. So again, there might be issues where, you know, you're having a hard time diagnosing a patient or getting them to do a workup that you're recommending. Education or literacy, employment issues, health risk factors, housing circumstances, social environment, upbringing, support groups, family circumstances, okay? It could be any, any of those categories, and I kind of gave you that category for diagnosis codes, ICD-10 codes to kind of reference, okay? Again, like Kathy said, you don't necessarily have to report that Z code on the claim. Just be sure to document in your assessment and plan as to what that social determinant is. Overall high risk, drug therapy requiring intensive monitoring for toxicity, and decision regarding elective major surgery with risk factors, all right? Decision for emergency major surgery, so it might be a patient transferred to the hospital for immediate appendectomy, or it could be a decision regarding hospitalization. Patient presents to clinic with significant symptoms that prompt the patient to be sent to the ER for admission. All right, let's talk about those risk factors for endoscopic procedures. So important. So with all these revisions, endoscopy procedures can either be considered minor, with or without risk factors, or major, with or without risk factors. It is, and this is probably the most important slide in this presentation. It's totally up to the provider to state the type of procedure and any risks to the patient by either documenting comorbidities or specific procedure risk, not just a templated statement that risks were explained to the patient. We know, you know, that's inherent of ordering an endoscopic procedure. That we hope that you're discussing risk factors, et cetera, that go with that procedure. These are identified risk factors to that patient. So it can't be just a template that you throw on the bottom of your note and every visit's going to be a level four. You have to make it specific. All right, so let's look at this example. Assessment. New patient presents with complaints of nausea, vomiting, along with epigastric pain. Plan. We'll schedule the patient for an upper GI endoscopy at the ASC. Instructions provided to the patient, all questions were answered. So based upon risk, 99203. So even though the complexity of problems is moderate, remember, we talked about the problems, the complexity of problems, data, and risk. Two of the three of those determine your overall level of service. All right, so the problem itself may be moderate for undiagnosed problem, but the overall risk is low and we didn't have data to increase that level. So this is a level three. Let's look at another example. New patient presents with complaints of diarrhea and lower abdominal cramping. We'll schedule the patient for an outpatient lower endoscopy to be done at the hospital. Patient is at a higher risk for this procedure due to his underlying conditions of CAD, diabetes, severe morbid obesity, with a current BMI of 46. So that's very specific. All right, what's this level? Level four. So complexity of problem is moderate and the risk is moderate for a minor procedure with identified risk factors. Number three. This is an established patient who has recently been diagnosed with pancreatic cancer. Patient has a significant pain, weight loss, jaundice, and fatigue. Recent imaging showed a significant structure of the bile ducts. Plan. At this point, we recommend the patient undergo an emergent ERCP for stent placement into the stricture. This is considered a minor, or sorry, major procedure for this patient given the diagnosis of cancer, severe weight loss, and fatigue. Patient also has significant jaundice. Risk and benefits were discussed with the patient and spouse. All questions answered. Level five for overall risk. Complexity of the problem is high and risk is high. Emergent major procedure. So you have two boxes checked there. Okay, so, so important to document your risk factors. We're going to talk a little bit about some tips. All right, and these are just some very common questions that we receive. So I thought, you know, we might as well address it. So in regards to external providers, okay, if you get credit, whether it's data, time spent, et cetera, an external provider is an individual not in your group, or practice, or is under a different specialty or subspecialty. And it includes licensed professionals that are functioning independently, may also be a facility or organization provider, such as a hospital, nursing facility, or home health agency, providers of different specialties or subspecialties in your own group do not count, okay. Speaking with another provider in your group does not count in calculating data. It may count towards your total time of the visit that day. Same thing with your records. You know, when you, when we, you review your own records, we can't count it as data, but we can count it into the time of your visit. So make sure, if you know your decision making may be low, et cetera, but you spent an extensive amount of time in the encounter, that's when you want to document your time. All right, what is the definition of a chronic stable condition? And I know I talked about, I talked about this under problems addressed. But this is a question that we get a lot. So it defines stable by the treatment goal set for the individual patient. If the patient is still symptomatic, still not at goal, it is not considered stable, even if the condition has not changed. Often providers use the term stable and not fully describe the patient's condition, or use the term stable and have contradictory information in the HPI. All right, so an example. HPI states patient has, says their abdominal pain has improved. Impression, stable IBS, continue the same medication. Or it could be a scenario where patient states abdominal pain has improved, but diarrhea is still about the same. Well, the impression, IBS not under control, refill medication. So it's all in the terms that you use, and what you tell us. Okay, what's considered intensive monitoring for toxicity? And remember, that's the, one of the categories under high risk. All right, so it could be monitoring by lab testing, physiologic testing or imaging. Monitored by visits does not, monitoring by visits does not qualify. The provider needs to specify which specific tests need to be repeated for toxicity issues. Patient received the first dose of Stelera on 10-1. He's doing well on Stelera, and it has been effective for his Crohn's. I recommend that he continue Stelera every two months. He has been doing well. He has developed mild constipation, but otherwise no new GI symptoms or bleeding. Labs found mild anemia and thrombocytopenia, which have been stable. Otherwise, normal CBC, CMP, LDH. Labs will be repeated in April. So you're telling me that the patient is on a medication, and we're monitoring issues by labs. Okay, just telling me that the patient's on medication that could be considered high risk for toxicity doesn't give you credit for it. You have to document what you're doing and what you're monitoring for. Let's talk about review of systems. Okay, this is another question that we get for medical decision making, or for, I'm sorry, for the E&M guidelines. It says, can you clarify if review of systems is required under new documentation guidelines? There is some confusion among staff if it is still required, it's still a requirement. I have informed them that although the driving factor of your visit is decision making or time to determine your level, the documentation still requires history and exam sections. Review of systems is a part of the history section, and many staff were informed the review of systems section is no longer a requirement. I have disagreed somewhat. I have told them it is not a requirement. However, if there are pertinent information such as GI system reviews should still be complete based on the information received from the patient. Normally in the past, nurses and assistant staff would complete this section based on information from the patient. They no longer are doing this since the documentation guidelines were changed. The clinical staff states that they've been placing this information in the HPI section of the note. Is this accurate? Or should there still be a review of systems section? Okay, it's actually a good question. This is kind of my response back to her. Although it's not a requirement for those visits, the history must relate back to the chief complaint. For example, if the patient comes in with nausea and vomiting, I would expect to see an HPI detailed element surrounding the nausea, vomiting and any pertinent history and pertinent review of systems such as fatigue or weight loss should be documented. Bottom line is that if you are asking the patient any symptoms, those should be documented. Though they no longer are a requirement to document a full 10 system review, the history should be, again, related back to the chief complaint. The exam is the same, okay? It has to be related back to the chief complaint. If the patient's coming in with abdominal pain, I expect to see a GI examination. It's up to the provider to make the decision as to what gets reviewed, not the clinical staff, okay? If you're still billing for consultation services, though, remember history and exam requirements are still in effect, okay? So it's up to the provider. Remember, anybody entering information into your note, whether it's the chief complaint, the HPI, the review of systems, you're responsible for it. If your name is on that claim, you're responsible. So if there's contradictory information, if there is no review of systems and you know you did a review of systems, put that information into your note before you sign that record.

medical decision-making

risk

endoscopic procedures

toxicity

documentation

note signing