Evaluation and Management Basics () - TRICARE文档.ppt

Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Track x – xxx day – 0000-0000 * Three Key Components Complexity and Medical Decision Making: Amount (number) of diagnoses or treatment options And/or complexity of data to be reviewed Risk of complications and/or morbidity or mortality Three Key Components Complexity and Medical Decision Making: ● Number of Diagnoses or Management Options Assessment, clinical impression, or diagnosis Self-limited or minor: stable, improved or worsening Est. problem: improved, well controlled, resolving or resolved; or inadequately controlled, worsening, or failing to change as expected New problem: no additional work up planned /additional work up planned Initiation of, or changes in, treatment Referrals, consultations requested or advice sought Three Key Components Complexity and Medical Decision Making: Amount and/or Complexity of Data to Be Reviewed Diagnostic test/procedure ordered, planned, scheduled, or performed Review lab, radiology and/or other diagnostic tests. Acceptable documentation: “WBC elevated” or “chest x-ray unremarkable” Report signed and dated Obtain old records/obtain additional history from other sources “Old records reviewed” or “additional history obtained from family” without elaboration is insufficient Three Key Components Complexity and Medical Decision Making: Risk of Significant Complications, Morbidity, and/or Mortality Comorbidities/underlying diseases or other factors Surgical or invasive diagnostic procedure ordered, planned or scheduled Surgical