Medical Decision Making. Michael Nauss MD FACEP Senior Staff HFH Dept. of Emergency Medicine

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Medical Decision


Michael Nauss MD FACEP

Senior Staff


Billing 101:

Down coding

Compared to national benchmark:

• HFH -1% on critical care

• When compared to Level 5 billing:

• Loss of $220 professional charges/pt

• Loss of $765 facility charges/pt

HFH -9% Level 5 charts

• When compared to Level 4 billing:

• Loss of $215 processional charges/pt



Focus on 10% of patients


Why do you care ?

You will…in less than 3 years

What is good for the dept. affects you


What can you do to help?

Improve documentation

 To reflect what we actually see and do

To reflect the complexity of our

patients and our workup’s


“Level 5 Chart”

HPI: Four

 location, quality, severity, timing,

associated sx, duration, context, modifying factors

ROS: Ten

• Constitutional, Eyes, ENMT, CV, Respiratory, GI, GU, MSK,

Integumentary, Neuro, Psych, Endocrine/Metabolic,


“Level 5 Chart”


 “Do you have any fever, chills,

nausea, vomiting, cough, sore throat, rashes or bruises, pain in your head, back, belly, chest, or burning when you urinate ?”


“Level 5 Chart”

PMHx, Family Hx, Social:

 Three: Epic does this for you (mostly)


 8 systems

• Constitutional, Eyes, ENMT, CV, Resp., GI, GU, MSK, Skin, Neuro., Psych,




In talking with coding…this is our #1


 Because we often don’t do it



 Presenting Problem

 Minimal

• one self limited minor problem

 Low

• 1 stable chronic prob. , 2 minor problems, or acute

uncomplicated illness/injury

 Moderate

• Mild exacerbation, 2 chronic stable problems, new problem/uncertain dx, acute illness

 High


MDM: Risk

Diagnostic procedures


• Labs (no IV), CXR or EKG


• X-rays (mult.), ABG


• CT AND x-rays



MDM: Risk

Management Options


• RICE, bandage, gargle




Critical Care

Can be billed by staff only


Medical Decision Making

Arguably the most important piece of

the medical chart

 HPI “paints a picture”


Common Mistakes

Missed information on

triage/EMS/nursing notes (general ED


 “worse HA of life”


Common Mistakes

Lack of patient reassessment


Common Mistakes

Poor consult documentation

 Who did you talk to and when

• Make consultant aware of charting


Common Mistakes

Discharge Instructions

 Ambiguous

No information on what to watch for or

why to come back

 Lack of follow up instructions (and


Common Mistakes

Non Documentation

 Procedures and failed attempts etc.

• Also hurts from a billing standpoint

 Information from old chart/OSH

 Repeat EKG’s (order and document)

 Adverse events


Community Experience

Regional Group

 Risk Management Audit

• Abdominal Pain

• Chest Pain

• HA

• Fever in Child

 CC’s represent 75% of dollars lost in


Community Experience

How this is done

 12 charts (3 per CC)

3-4 months after hire

 Sit down evaluation with Risk


HFH Experience

Charting metric

 Twice a year for PGY-2 and above


Building a Chart

EMR dependent

 Typing is not ideal (…job seekers)

Be aware of templates/macros

• LE Amputees with +2 DP/PT pulses bilaterally are unusual and hard to find


How to Put it Together

Just put it somewhere

 MDM section

• Reassessment (.now phrase)


How to Put it Together



• This is a patient who presented with cough and SOB

ED Course

• Pt. was given nebs/steroids and labs/cxr were obtained

 Studies

• Labs unremarkable (.edlabs)


How to Put it Together


 Patient Response to Tx:

• Pt states she felt better after tx

• Eating/Up and ambulatory in ED


How to Put it Together

Evaluate the Differential Dx.

 Based on…. I doubt ….

• EKG unchanged, no exertional

component to symptoms I doubt ACS

• No leg swelling/pain, no travel or recent surgery I doubt PE

 Given …. I favor ….


How to Put it Together

 Case for Discharge/Treatment Plan

Why is this COPD exacerbation going


• Given pt. does not desat. during ambulation, is afebrile, feels improved, I feel they can be d/c with oral steroids and abx as well and increase home neb. use

Follow up

 Phone call

 Ability to obtain timely f/u

• iPhone etc.


How to Put it Together

Discharge Info.

 Spell out exactly what to watch for and

reasons to seek further care

 Follow up (did you talk with PMD)

 “…return if worse or if concerned”

 Incidental findings: document in chart

and on d/c Instructions


How to Put it Together


Case for Admission

Medical Necessity

 Important for billing (ATMO/IPAS too)

 Why is this COPD exacerbation being

admitted ?

• Increased O2 requirement

• Abnormal CXR


Coding Queries

As of 7/31

 $ 55,000 waiting on resident charting

(queries only) to be billed

Finish carts same day/next day

Respond to queries ASAP (even off





 Needs to play a larger role in


 Should reflect disposition thought

processes and data

 Must include commonly missed items

• Abnormal VS, reassessments etc.

 Follow up and discharge instructions





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