Let’s apply those guidelines to one of our most common problems that we see at the clinic; dry eyes. Dr. Cockrell, can you walk us through those three elements again and you know how would you go and utilize that medical decision making model with a case like dry eyes?
Okay, great Maritza. Let’s talk through this just a little bit and then you know, just as a point of reference, if I were in practice now and especially if I was in a multi doctor practice, but even if I was by myself, I probably would keep track of every pathology problem or every medical problem that I saw or had seen maybe in the previous few months and I would sit down and code all of those problems so that when a patient came in, I basically already know. I basically already know, because I’ve done the exercise based on patients that I’ve seen previously and speed up my coding process pretty dramatically. And I also, thank goodness for computers, I would also probably keep this AMA medical decision making grid on my computer or hope that I had multiple monitors in my exam room, so if I need my chair side assistant to pull this grid up, I could just have them pull the grid up and take a look and it's pretty easy and we know for sure that our documentation supports what we coded because that's the real issue in the audit. Does our documentation match what we've coded? If it does, then we’re fine. And of course the second problem as we alluded to, is the potential for some kind of negligence suit. And those are going to hinge a lot on the whole history of present illness and chief complaint and review of systems, even though they are not used in coding, it's still a critical part of your exam.
So, let’s talk about dry eyes for just a second. It’s pretty common, seen in just about everyone’s office and it would be, I think a real advantage for every practice to have coded this out previously and know without looking all the time, how they are really going to code this. So, the patient presents with maybe itchiness, maybe dryness, redness. There may be problems with the lids. There might be multiple signs there, but we still probably have one problem and where does that problem rank. Probably ranks in one, could be one acute uncomplicated illness or injury or maybe even one stable chronic illness, if the patient being treated doesn't have issues. If it’s an initial visit, so with that in mind, we would probably code that particular element as low on the number of problems and complexity. However, if it's the initial visit and it's an undiagnosed new problem, with uncertain diagnosis, then that's a different thing and it drops you immediately into a level four. So your initial visit, you might be a level four on this particular element, on a follow up visit more likely a level three.
When we drop over into the second element of data complexity. In most cases, I think we're probably still going to fall into the low category. We may order tests, but probably not going to be outside our office most of the time. So, there's debate on whether we could use ordering of each unique test as one of the bullets under category one or not. And then, review of external notes, we may or may not have that, most of the time we're probably not going to have that. And then reviewing the tests, reviewing the results of the test. If a test that we ordered inside our office, we're probably safer to not separate the act of ordering the test and the act of doing the test, because we're already billing for the test and the interpretation report. It’s debatable and as I mentioned earlier, to some certified professional coders, even certified professional auditors, do believe that the act of ordering the test, is separate from the act of performing the test and could be counted. So, we might meet that and probably do meet that for the low complexity or limited. Category two about the assessment requiring an independent historian, most of the time we're probably not going to meet that. We're going to use category one. If we’re trying to reach a moderate level, then certainly we’re going to have to get three of those components in category one. And as I mentioned, depending on how you interpret the act of ordering the test as being separate from the act of performing the test, or whether you’re combining that, that's going have a lot to do with whether you can actually meet those. And then of course, whether the patient has been referred or they initially presented it with a problem in your office. In most cases, I’m going to say it probably drops into limited or level three.
And then of course when we get to risk of complications and or morbidity or mortality from patient management, we've got a fairly low risk, well I think an extremely low risk of mortality and a low to potentially moderate risk drug management if we're not prescribing any real treatment there then other than just following and it resolves on its own, then low risk. However most of the time, we may be prescribing a prescription, especially if its initial presentation. We might prescribe Lotemax and as it goes down the road, we might prescribe Zybrim. And so you’re immediately going to drop into a level four there. But if we throw out our lowest, either element one or element two, but we’re still going to bill on the next lowest element. So, in a follow up visit, we’re probably going to have two of them, two elements in the low, level three category and one in the moderate or level four. So we’re going to bill a level three. If it’s initial presentation and we decided a number of problems in complexity addressed, that we’re going to identify and support of our documentation, that its an undiagnosed new problem with uncertain prognosis and now we’re at a level four, regardless of what we get in level, in data complexity, we’re probably going to throw that out, because we’re going to jump right to the risk of treatment and we’ve got prescription drug management if in fact we have prescribed and we’re going to follow that. So, now we're throwing out the data complexity or element two as being our lowest scored element and we’re left with our next lower element being moderate. So, our initial presentation would be a level four.
And Dr. Cockrell, I do also kind of want to note there, any time that there is a change to that prescription it would go back to that prescription management, so if at that follow-up visit you're prescribing a different medication that would again put you back to that moderate risk due to the prescription management. So anytime you are starting, stopping, or continuing a medication, that should be an element under risk assessment, correct?
Absolutely! And thank you for reiterating that.