A. Location
B. Quality
C. Severity
D. Duration
E. Timing
F. Context
G. Modifying Factors
H.Associated Signs and Symptoms
We obviously are doing much more than that. Which is why most often our physica exams fall in the Expanded Problem focused, where you require 6 bullets in one or more organ systems. BTW you get 1 bullet for Vitals and One for General Appearance. Which you should do every time! Then you listen to the heart. Murmurs? No. 1 bullet, PMI shift No? 2 Bullet that’s 4 bullets. So do you think you could get 2 more? Yes, most often we do. Which is why you rarely use the Level 2 99212…
But lastly in case you didn’t make one of the previous 2 categories….you always have medical decision making. In the case of 99212 the level of decision making is straightforward medical decision making. Which in essence means you didn’t need t o review or to think…..
What is straightforward MDM?
Straightforward Medical Decision-Making is the lowest level of Medical Decision-Making. It is impossible not to qualify for it.
It requires that you meet 2 of the 3 categories with One Point in each OR one category and MINIMAL Medical Risk.
What does that entail? Well, you can review my medical decision making post or you can just see right here
MDM is broken up into Problem Points, Data Points and Risk of Morbidity or Mortality from Disease.
Problem Points are
4 Points-New Problem, New Work up
3 Points-New Problem, No Work Up
2 Points-Established Problem, Worsening
1 Point-Established Problem, Stable
Data Points are
2 Points-Independant review of EKG or Radiology or Specimen
2 Points-Review of Old Records
1 Point-Ordering or Reviewing Labs
1 Point-Discuss results with OTHER physician
1 Point-Ordering tests (EKG/CXR/Cath)
1 Point-Decision to obtain old records
Risk in this case is Minimal Which means “Self limited or minor problem”
Risk is determined by 3 Things
1. Presenting Problem
2. Diagnostic Procedures
3. Management Options Selected
Source – Medicare25.blogspot.com
Still Conufsed? You can check the Table of Risk at EM University for further clarification.