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15 Cards in this Set

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*DATA REVIEW

Why is documentation of the review of results important?
-Without documentaion, the review did not happen from the standpoint of third-party payer reimbursement. The physician must note the relevant findings and sign off on the review of all data documented for a particularencounter in order for that data to be considered for coding and reimbursement purposes.
Why would old medical records be requested and reviewed?
-Old records may provide historical data that will aid in the diagnosis and treatment of the current condition. The request for these items must be documented and the relevance noted in order for them to be counted in determining the coding of the encounter
*RISKS

Why is the effect of risk of morbidity, complications, or mortality on MDM level?
-The higher the risk level, the higher the MDM is likely to be because the consequences of not providing comprehensive management and data review are significant enough to provide medical justication for increased service levels.
How might the presence of other diseases and factors affect the risk level?
-Treatment protocols may be different for patients who suffer from chronic illnesses or have other chronic conditions that affect general health.
How does urgency factor into calculation of risk?
-Acute conditions such as a heart attack or a ruptured appendix will result in death if not treated promptly, even though the risk of death may be slight if they are treated. The MDM level is elevated as a result of this increased risk to the patient.
*FOUR RISKS LEVELS

Does an elevated risk level automatically result in higher levels of data review and prient management?
-Not necessarily. The diagnostic and management options available may be clear-cut and limited in number, as would be the case in treatment of a ruptured appendix. The quantity and complexity of the data to be reviewed is likely to be higher than in a case where risk is high than wheer risk is minimal, but may not be at the extensive level in that case. It varies with the specifies of the patient's presenting conditions.
*MINIMAL
Why is the risk level of a wasp bite minimal?
-With the exception of individuals who are highly allergic, patients will recover without treatment from this event, which makes it self-limiting. Mild discomfort may be alleviated by palliative treatment, but such treatment will not markedly affect patient outcome.
*LOW

Why would the risk level be elevated when several wasp bites were received?
-While a single wasp bite is merely uncomfortable, multiple bites may be more likely to provoke an allergic reaction or cause some other side-effect if not treated. As a result of the need for treatment to secure a positive outcome, the risk associated with this event is somewhat elevated, though still low.
MODERATE

Why is the risk level elevated for those with chronic conditions even if they are stable?
-An unstable chronic condition elevates risk level because it may complicate treatment and result in an adverse outcome in and of itself. Even stable conditions affect the risk level because the impact of treatment on the conditions must be considered in addition to its impact on the chief complaint. The possibility of adverse reactions from treatment will elevate risk level.

In the case of the undiagnosed condition with unknown prognosis, the risk level cannot be known until the diagnostic information is obtained. The patient must be treated in the interim in accord with the risk level associated with an adverse outcome from the breast biopsy. i.e., a diagnosis of cancer. Failure to do so would increase the risk of morbidity and/or mortality. With an acute illness like pneumonia, patients may recover if treated promptly or may become worse if treatment is delayed. The risk is moderate as long as prompt treatment is provided.
*HIGH

# Why is It important to note any chronic illnesses in the patient record?
-Assuming the chronic condition is relevant to the chief complaint, it is important to note because it can affect a number of factors, including the risk level assigned to the encounter Patients with malignant hypertension and uncontrolled diabetes are at high risk for a number of complications, including possible death. A patient with uncontrolled diabetes but normal blood pressure would have less risk. If the documentation is present for the malignant hypertension, the risk level would have to be coded as moderate.
#Why is the risk level greater with a life-threatening illness?
-A life-threatening illness poses imminent riskof death if not treated quickly. The level of service required is likely to be greater because there is no time to plan. The experience required to treat it would also be greater than with a less significant condition.
#How do the MDM levels differ from one another?
-Straightforward MDM has minimal diagnostic and data complexity and minimal risk.

-Low MDM has levels of each that are limited, but elevated compared to the straightforward MDM.

-Moderate levels of each are elevated when compared to low.

-High have extreme levels of each element in place.
*Review of Three Key Components

#How are the three key components used to determine the level of medical service provided?
-The levels of the three key components collectively determine the level of service provided. They are present in every patient encounter to one degree or another.
*History

#What are the elements that determine the level of patient history?
-CC,HPI,ROS,PFSH
#What are the key differences in the four levels of history?
-The problem-focused history addresses the chief complaint and includes an HPI.

-The expanded problem-focused history adds an ROS for systems related to the chief complaint.

The detailed history adds a more extensive ROS that includes related systems and also includes PFHS as it pertains to the chief complaint.

-The comprehensive history adds a complete ROS and a complete PFSH.