Abstract:
A learning system for medical coding comprising: analyzing patient history before examination; charting the patient history on a historical component table; providing a summary of the patient history; determining an examination component of coding; tabulating data reviewed; determining risk complications and managing a course of action based on the data. The patient history includes: a chief complaint, a history of present illness, review of the patient&#39;s various systems and post-family or social history. The examination component may include the organ system and body area of a patient. Further, the course of action includes three elements, numbering of diagnosis and management options, amount and complexity of data reviewed, risk of complication and morbidity or mortality. Any tabulated data includes pathology, radiology and complex test results.

Description:
BACKGROUND OF THE INVENTION 
       [0001]    1. Field of Invention 
         [0002]    The present invention relates to a system and method to educate and learn medical coding systems. 
         [0003]    2. Description of Related Art 
         [0004]    Medical field includes a classification or coding system that provides codes for medical diagnoses and medical procedures. Further coding is also related to pharmaceutical and topographical coding, where topographical coding is related to particular locations of a patient&#39;s body. The medical coding system provides universal medical coding numbers that are associated with particular diseases and health conditions. The procedural codes coincide with the actual procedures that are performed based upon the associated diagnosis. This coding system is used throughout the medical field and applied in public health facilities, government health programs, health insurance providers, workers&#39; compensation providers and other aspects of the medical health administration. Many medical professionals are required to learn such “coding” in order to provide accurate and adequate records of medical procedures and diagnoses performed. Typical coding is learned through a training process that sometimes can be time consuming and difficult for students. Subsequently it would be advantageous to have a system and a supporting software that can help in the teaching and learning of medical coding systems. 
       SUMMARY OF THE INVENTION 
       [0005]    The present invention relates to a learning system for medical coding comprising of: 
         [0006]    Determining the individual levels of service for each key component: 
         [0007]    History, Examination, and Medical Decision-Making from the documentation. We analyze the three key components-history, examination, and medical decision-making. We figure out what level of service is documented for each key component. Each key component has its own unique set of service levels. 
         [0008]    First we have to figure out what level of service is performed for the history component. We analyze the patient history before the examination, charting the patient history on a historical component table, providing a summary of the patient history. 
         [0000]    There are four levels of service for the history component.
 
The four levels are:
 
Problem focused, Expanded problem focused, Detailed, Comprehensive.
 
Each level of service has certain requirements.
 
The history component consists of four elements:
 
         [0009]    1. Chief complaint (CC) 
         [0010]    2. History of present illness (HPI) 
         [0011]    3. Review of systems (ROS) 
         [0012]    4. Past, family, and/or social history (PFSH) 
         [0013]    We then analyze each element CC, HPI, ROS, PFSH based on the patients chart and the levels of service is also included in the chart. Under each table there are specific rules to help choose and to find the final level. We then circle the elements we find in the scenario. After that we compile all of information from the previous tables and put them in the summary tables to determine the overall history component. 
         [0014]    The lowest of all components determines the level of service for the history component. The chart help to figure out which history elements are required to each history level of service. It also shows how much information must be included for an element to qualify for a specific level of service. 
         [0015]    The second key component for the Evaluation and management level of service is: The Examination Component. We have to figure out what level of service is performed for the examination component. As with the History Component, there are four levels of service for the examination component. 
         [0016]    The four levels are: 
         [0017]    1. Problem focused 
         [0018]    2. Expanded problem focused 
         [0019]    3. Detailed 
         [0020]    4. Comprehensive 
         [0000]    Each levels of service have certain requirements.
 
The Examination Component consist of two elements:
 
         [0021]    1. Organ System (OS) 
         [0022]    2. Body Areas (BA) 
         [0023]    We analyze the information of the patient according to the list of Organ and Body Areas. After we circle how many elements we find in the Examination Component table. The levels of service are also included in the chart. The charts are designed to help you determine the accurate level of service for the Examination Component. 
         [0024]    The third (final) key component is: Medical Decision-Making. The Medical Decision Making has four levels of service. 
         [0025]    The four levels are: 
         [0026]    1. Straightforward 
         [0027]    2. Low Complexity 
         [0028]    3. Moderate Complexity 
         [0029]    4. High Complexity 
         [0000]    Each level of service has certain requirements. The Medical Decision-Making consists of the three elements: 
         [0030]    1. Number of Diagnoses and Management Option. 
         [0031]    2. Amount and/or Complexity of Data Reviewed 
         [0032]    3. Risk of complication and/or Morbidity or Mortality 
         [0033]    We figure out what level of service is performed for the Medical Decision-Making. We determine the level of service for each element of the Medical Decision-Making based on the patient&#39;s chart. The levels of service are also included in the chart. Each table help to choose and find the final level. We then circle the elements we found in the scenario. After that we compile all of the information from previous tables and put them in the summary table to determine the overall medical decision making. 
         [0034]    After that the lowest level is crossed out and then pick the next highest. Lowest level is crossed out and then pick the next Highest is the determination of the overall level of Medical Decision Making. 
     
    
     DETAILED DESCRIPTION 
       [0035]    The present invention relates to a medical coding system-in particular a system that enables a user to learn medical coding. The present system provides a user a system to learn diagnostic and procedural coding. The diagnostic and procedural coding is associated with two stages. 
         [0036]    Stage one with an evaluation and management procedure related to the place of the services, types of services and the patient&#39;s status. 
         [0037]    The second stage relates to the determining the individual levels of service for each key component: history, examination, and medical decision-making. 
         [0038]    We figure out what level of service is documented for each key component. For example, a level of service for the history component will tell you how extensively the medical history is documented. A level of service for the Medical Decision Making Component will tell you the complexity of the decision. 
         [0000]    Each key component has its own unique set of service levels. 
       First Key Component 
       [0039]    First we have to figure out what level of service is performed for the History Component. Patients are evaluated initially to determine their history before examination. The patient history is associated with a particular coding that implemented by the medical professional. 
         [0000]    The history component has four levels of service.
 
The four levels are:
 
         [0040]    1. Problem Focused 
         [0041]    2. Expanded Problem Focused 
         [0042]    3. Detailed 
         [0043]    4. Comprehensive 
         [0000]    Each level of service has certain requirements. These requirements incorporate not only what history elements were included in an E/M procedure, but to what degree.
 
For example, was there a brief or extended history taken for the present illness or problem?
 
The history component analysis relates essentially to four elements:
 
         [0044]    1. Chief Complaint (CC) 
         [0045]    2. History of Present Illness (HPI) 
         [0046]    3. Review of Systems (ROS) 
         [0047]    4. Past, Family, and/or Social History (PFSH) 
         [0048]    We analyze each element: CC, HPI, ROS, PFSH based on the patient&#39;s chart. 
         [0000]    The levels of serve are also included in the chart. 
         [0049]    The present invention uses history component tables as shown below to analyze each particular element based upon the patient&#39;s chart. The chart help to figure out which history elements are required for each history level of service. It also shows how much information must be included for an element to qualify for a specific level of service. For example, for detailed level of service for the history component, the HPI must be Extended. For an Expanded Problem Focused level of service for the history component, the HPI only needs to brief. To determine the level of history, we will use the following table: 
         [0000]    
       
         
               
             
               
               
               
             
           
               
                   
               
               
                 History Component Table 
               
             
          
           
               
                 Check 
                 Key Components 
                 Required 
               
               
                   
               
               
                   
                 CC 
                   
               
               
                   
                 Describe the symptom, problem, 
               
               
                   
                 or condition that is the reason 
               
               
                   
                 for this encounter: 
               
               
                   
                 HPI 
                 Number of 
               
               
                   
                 Location? 
                 Characteristics: 
               
               
                   
                 Quality? 
                 1-3 = Brief 
               
               
                   
                 Severity? 
                 4 or more extended 
               
               
                   
                 AS&amp;S 
               
               
                   
                 Timing? 
               
               
                   
                 Duration? 
               
               
                   
                 Context? 
               
               
                   
                 Modifying Factors? 
               
               
                   
                 ROS 
                 Number of Systems: 
               
               
                   
                 Constitutional? 
                 1 = Problem Pertinent 
               
               
                   
                 Eyes? 
                 2-9 = Extended 
               
               
                   
                 Ears, Nose, Mouth, Throat? 
                 10 or more Complete 
               
               
                   
                 Cardiovascular? 
               
               
                   
                 Respiratory? 
               
               
                   
                 Gastrointestinal? 
               
               
                   
                 Genitourinary? 
               
               
                   
                 Musculoskeletal? 
               
               
                   
                 Integumentary? 
               
               
                   
                 Neurological? 
               
               
                   
                 Psychiatric? 
               
               
                   
                 Endocrine? 
               
               
                   
                 Hematologic/Lymphatic? 
               
               
                   
                 Allergic/Immunologic? 
               
               
                   
                 PFSH 
                 Number of Elements: 
               
               
                   
                 Past History 
                 1 of 3 = Pertinent 
               
               
                   
                 Past Medical history 
                 2 of 3 = Complete 
               
               
                   
                 Illness/injury 
               
               
                   
                 Current medications 
               
               
                   
                 Past operations 
               
               
                   
                 No allergies (you can count) 
               
               
                   
                 Family History 
               
               
                   
                 Medical events in patients family 
               
               
                   
                 Health status of family 
               
               
                   
                 Family Diseases 
               
               
                   
                 Social History 
               
               
                   
                 Marital Status 
               
               
                   
                 Employment 
               
               
                   
                 Level of education 
               
               
                   
                 Sexual history 
               
               
                   
                 Drugs 
               
               
                   
                 Alcohol 
               
               
                   
                 Tobacco 
               
               
                   
                 Denies alcohol use (can count) 
               
               
                   
               
               
                 We analyze each element CC, HPI, ROS, PFSH based on the patient&#39;s chart. Under each table there are specific rules to help choose and to find the final level. We then circle the elements we find in the scenario. 
               
             
          
         
       
     
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 1) CC (Chief Complaint 
               
             
          
           
               
                   
                 Problem 
                 Expanded 
                   
                   
               
               
                 History 
                 Focused 
                 Problem 
                 Detailed 
                 Comprehension 
               
               
                   
               
               
                 CC 
                 required 
                 required 
                 required 
                 required 
               
               
                   
               
             
          
         
       
     
         [0050]    We circle the highest documented level. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 2) HIP (History of Present Illness) 
               
             
          
           
               
                   
                 Problem 
                 Expanded 
                   
                   
               
               
                 History 
                 Focused 
                 Problem 
                 Detailed 
                 Comprehension 
               
               
                   
               
               
                 HPI 
                 Brief 
                 Brief 
                 Extended 4 
                 Extended 4 
               
               
                   
                 1 to 3 
                 1 to 3 
               
               
                   
               
             
          
         
       
     
         [0051]    The goal is to code to the highest level documented. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 3) ROS (Review of System) 
               
             
          
           
               
                   
                 Problem 
                 Expanded 
                   
                   
               
               
                 History 
                 Focused 
                 Problem 
                 Detailed 
                 Comprehension 
               
               
                   
               
               
                 ROS 
                 N/A 
                 Pertinent 
                 Extended 
                 Complete 
               
               
                   
                   
                 1 system 
                 2 to 9 
                 10 
               
               
                   
               
             
          
         
       
     
         [0052]    We circle how many elements we find in the list of systems based on the scenario. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 4) PFSH (Post Family and or Social History) 
               
             
          
           
               
                   
                 Problem 
                 Expanded 
                   
                   
               
               
                 History 
                 Focused 
                 Problem 
                 Detailed 
                 Comprehension 
               
               
                   
               
               
                 PFSH 
                 N/A 
                 N/A 
                 Pertinent 
                 Complete 
               
               
                   
                   
                   
                 1 of 3 
                 2 of 3 
               
               
                   
               
             
          
         
       
     
         [0053]    We circle how many elements we find in the scenario. 
         [0054]    The chart provides a scenario where specific rules are applied to each particular area of the history. Various areas of history may require analysis of a small number of characteristics based upon the patient&#39;s condition. The analysis of the history is compiled and provided in a summary of history table as shown below. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 SUMMARY HISTORY TABLE 
               
             
          
           
               
                   
                 Problem 
                 Expanded 
                   
                   
               
               
                 History 
                 Focused 
                 Problem 
                 Detailed 
                 Comprehension 
               
               
                   
               
               
                 CC 
                 required 
                 required 
                 required 
                 required 
               
               
                 HPI 
                 Brief 
                 Brief 
                 Extended 4 
                 Extended 4 
               
               
                   
                 1 to 3 
                 1 to 3 
               
               
                 ROS 
                 N/A 
                 Pertinent 
                 Extended 
                 Complete 
               
               
                   
                   
                 1 system 
                 2 to 9 
                 10 
               
               
                 PFSH 
                 N/A 
                 N/A 
                 Pertinent 
                 Complete 
               
               
                   
                   
                   
                 1 of 3 
                 2 of 3 
               
               
                   
               
             
          
         
       
     
       Level of Service for the History Component 
       [0055]    The lowest of all components determines the level of service for the history component. This complies all of information from the previous tables and puts them in the summary tables to determine the overall history component.
 
The chief compliant and history of the present illness provide the highest level of documentation. Then a review of the system and post-family or social history is provided in detail based upon the number of systems involved. The level of service may be expanded based upon the problem encountered.
 
The second key component for the Evaluation and Management level of service is:
 
       The Examination Component. 
       [0056]    This is the description of the findings from the physician&#39;s examination of the patient. The History Component was subjective, or fiction. The examination component is objective, based on factual date the physician has determined. We have to figure out what level of service is performed for the examination component. As with the History Component, there are four levels of service for the examination component.
 
The four levels are:
 
         [0057]    1. Problem focused 
         [0058]    2. Expanded problem focused 
         [0059]    3. Detailed 
         [0060]    4. Comprehensive 
         [0000]    Each level of service has certain requirements.
 
The Examination Component consist of two elements:
 
         [0061]    1. Organ System (OS) 
         [0062]    2. Body Areas (BA) 
         [0063]    We analyze the information of the patient according to the list of Organ and Body Areas. Only one item in each OS/BA needs to be documented. After, we circle how many elements we find in the Examination Component table. The levels of services are also included in the chart. The charts are designed to help you determine the accurate level of service for the Examination Component. The present invention uses a examination table as show below to analyze each particular element based upon the patient&#39;s chart. The charts help to figure out which examination element are required for each examination level of service. The examination component provides an organized approach for patient analysis to be used in accordance with medical coding. The determination of the examination component tables therefore helps to identify the components of examination as needed. 
         [0000]                                          Examination Component Table                                Check   Organ Systems   Number of Organ           Constitutional?   Systems           Eyes?           Ears, Nose, Mouth, Throat?           Cardiovascular?           Respiratory?           Gastrointestinal?           Genitourinary?           Skin?           Musculoskeletal?           Neurological?           Psychiatric?           Hematologic/Lymphatic/Immunologic?           Body Areas   Number of Body           Head, Face?   Areas Documented           Neck?           Chest, Breast, Axilla?           Abdomen?           Genitalia, Groin, Buttock?           Back, Spine?           Each Extremity?                    
After that we compile all of information from the previous table and put them in the summary tables to determine the overall Examination Component. The level of service for the Examination Component determine based upon the number of systems involved. For instance, the level of service for Examination Component is: Expanded Problem based upon the (2-4OS/BA) elements we find in the examination table component from the patient&#39;s chart.
 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 Summary Examination Table 
               
             
          
           
               
                   
                 Problem 
                 Expanded 
                   
                   
               
               
                 Exam 
                 Focused 
                 Problem 
                 Detailed 
                 Comprehension 
               
               
                   
               
               
                   
                 1 OS/BA 
                 2-4 OS/BA 
                 5-7 OS/BA 
                 8 OS 
               
               
                   
               
             
          
         
       
     
       Level of Service for the Examination Component 
       [0064]    The Third (final) key component of Medical Coding is: Medical Decision Making. The Medical Decision Making has four levels of service. 
         [0065]    The four levels are: 
         [0066]    1. Straightforward 
         [0067]    2. Low Complexity 
         [0068]    3. Moderate Complexity 
         [0069]    4. High Complexity 
         [0000]    Each level of service has certain requirements. 
         [0070]    The Medical Decision-Making consists of the three elements: 
         [0071]    1. Number of Diagnoses and Management Option. 
         [0072]    2. Amount and/or Complexity of Data Reviewed 
         [0073]    3. Risk of complication and/or Morbidity or Mortality
       We need to figure out what level of service is performed for the Medical Decision-Making. We determine the level of service for each element of the Medical Decision-Making based on the patient&#39;s chart. The levels of service are also included in the chart. Each table helps to choose and find the final level.       
 
         [0075]    We then circle the elements we found in the scenario. After that we compile all of the information from the previous tables and put them in the summary table to determine the overall medical decision-making. After that, the lowest level is crossed out and one must pick the next highest level to determine the overall level of Medical Decision Making. 
         [0076]    1. Number of Diagnoses and Management Options. 
         [0077]    This element of Medical Decision-Making relates in particular to the problem and diagnoses/plan of action. To determine the level of service for this element we analyze the problem and the plan of action. The Diagnosis and Management table presents a number of problems and plan of action. We use this table that is designed to help for determine the final level of service for decision making for this element. We will analyze the information of the patient according to this table and after we will circle the level we found on the Diagnosis and Management table on the other management table. 
         [0078]    For example: the decision making becomes extensive based upon additional work-up planned of the patient. As shown the self-limited or minor problems becomes minimal decision making based upon plan of action (stable, improving, worsening) of the patient analysis. If the level is Minimal after we have analyzed the information of the patient according to the Diagnosis and Management table. Number of diagnosis and management option has four levels: 
         [0079]    1. Minimal 
         [0080]    2. Limited 
         [0081]    3. Multiple 
         [0082]    4. Extensive 
         [0000]    We use the table that is designed to help to determine the level of service for decision making for this element. 
         [0000]    
       
         
               
             
               
               
               
               
             
           
               
                   
               
               
                 Diagnosis Management Options Table 
               
             
          
           
               
                   
                   
                 Decision 
                   
               
               
                 Problem 
                 Diagnosis/Plan of Action 
                 Making 
                 Check 
               
               
                   
               
               
                 Self-limited or minor 
                 Stable, improving, 
                 Minimal 
                   
               
               
                   
                 worsening 
               
               
                 Established w/ Doctor 
                 Stable, improved 
                 Minimal 
               
               
                 Established w/ Doctor 
                 Worsening 
                 Limited 
               
               
                 New to Doctor 
                 No additional work-up 
                 Multiple 
               
               
                   
                 planned 
               
               
                 New to Doctor 
                 Additional work-up planned 
                 Extensive 
               
               
                   
               
             
          
         
       
     
         [0083]    Patient information is analyzed according to this table and the level may be indicated we found on the Diagnosis and Management table on the other management table. See below 
         [0000]    
       
         
               
               
               
               
               
             
           
               
                   
               
               
                   
                   
                 Low 
                 Moderate 
                 High 
               
               
                 MDM 
                 Straightforward 
                 Complexity 
                 Complexity 
                 Complexity 
               
               
                   
               
             
             
               
                 Dx/Mgmt 
                 minimal 
                 limited 
                 multiple 
                 Extensive 
               
               
                   
               
             
          
         
       
     
         [0084]    2. Amount and/or Complexity of Data Reviewed is: 
         [0085]    The second element of the MDM (Medical Decision Making) component involves counting what is documented. Documenting the results of a lab test counts toward reviewing date for pathology. We use the table (Amount and/or Complexity of Data Reviewed) that depicts specific information to help determine the level service for decision making for this element. If you look at this table the patient may require data from pathology, radiology, complex test results and further may require an examination of old medical records or addition history. The total score determines the level of decision making for this element. 
         [0000]    The levels of service for this element are four: 
         [0086]    0 to 1-Minimal or None 
         [0087]    2-Limited 
         [0088]    3-Moderate 
         [0089]    4 of more-Extensive 
         [0090]    We will analyze the information of the patient according to this table and after we will circle the level we found on the date reviewed table, on the other management table.
       Amount and/or Complexity of Data Reviewed       
 
         [0092]    To determine the level of this service we will use the following table: 
         [0000]                                          Data Reviewed Table            Check   Score   Data Reviewed                   (1)   Pathology &amp; Laboratory: One or more tests           (1)   Radiology: One or more tests           (1)   Other Diagnostics Studies: One or more studies or               services           (2)   in CPT 90701-99199               Complex test results: Direct visualization, independent               interpretation of specimen, image or tracing previously           (1)   interpreted by another MD. Each test is counted               separately.           (2)   Old records or additional history: Evaluating need for or               decision to obtain.           Total   Summarizing review/obtaining additional history from           Score   family, caretaker, or other source.           0 to 1   Level of Service for Amount and/or Complexity of Data           2   Reviewed           3           4   Minimal or None           or   Limited           more   Moderate               Extensive                    
The total score determines the level of decision making for this element.
 
         [0093]    As shown the charts are designed to help you determine the accurate level of service for the amount and/or complexity of data review. The amount and/or complexity of the data review therefore creates a scale related to the final determination of coding associated with this diagnostic procedure. 
         [0000]    
       
         
               
               
               
               
               
             
           
               
                   
               
               
                   
                   
                 Low 
                 Moderate 
                 High 
               
               
                 MDM 
                 Straightforward 
                 Complexity 
                 Complexity 
                 Complexity 
               
               
                   
               
             
             
               
                 Data 
                 Min/none 
                 limited 
                 moderate 
                 extensive 
               
               
                   
               
             
          
         
       
     
         [0094]    The score we found in the table above this one we circle the level on this table. 
         [0000]    3. Risk of Complication and/or Morbidity or Mortality is: 
         [0095]    The third element of Medical Decision Making. For determining the level of service for this element, we use the table of risk that is designed for this process. If you read through the table the level of risk at the far left column. 
         [0000]    There are four levels of service: 
         [0096]    1. Minimal 
         [0097]    2. Low 
         [0098]    3. Moderate 
         [0099]    4. High 
         [0000]    The type of risk is categorized by: 
         [0100]    The presenting problem, the diagnostic procedure(s) ordered, and by the management options selected. This element of decision-making is determined by the highest level of risk in any one category. The Minimal Risk due to one self-limited or minor problem, requires laboratory test and also needs rest, gargles, etc. The High Risk has one or more chronic illnesses, which requires cardiovascular imaging studies and also needs emergency major surgery. 
         [0101]    Between minimal risk and high risk are different management options selected and also diagnostic procedure(s) ordered. The Moderate has one or more chronic illnesses with mild exacerbation and requires diagnostic endoscopy with no identified risk factors and also needs minor surgery with identified risk factors. The low risk has two or more self-limited or minor problem, requires superficial needle biopsies and also needs minor surgery with no risk factors. To determine the level of service for this element we use this table. We will analyze the information of the patient according to the table of risk and after we will circle the level we found on the table of risk, on the other management table. 
         [0000]    3. Risk of Complications and/or Morbidity or Mortality 
         [0102]    To determine the level of service for this element we will use the following table: 
         [0000]                                                  Table of Risk                        Diagnostic                   Presenting   Procedure(s)   Management       Check   Level of Risk   Problem(s)   Ordered   Options Selected                   Minimal   One self-limited or   Laboratory tests   Rest, gargles;               minor problem   requiring   elastic bandage                   venipuncture; chest   superficial                   x-ray; EKG/EEG;   dressing                   urinalysis;                   ultrasound           Low   Two or more self-   Superficial needle   Over-the-counter               limited or minor   biopsies, clinical lab   drugs; minor               problems; one   tests with arterial   surgery w/no risk               stable, well-   puncture,   factors; IV fluids               controlled chronic   physiological tests   w/o additives;               illness; acute   not under stress,   physical or               uncomplicated   non-cardiovascular   occupational               illness or injury   imaging studies with   therapy                   contrast           Moderate   One or more   Diagnostic   Minor surgery               chronic illnesses   endoscopies with no   w/identified risk               with mild   identified risk   factors;               exacerbation; two   factors; obtain fluid   prescription drug               or more stable   form body cavity   management; IV               chronic illnesses;   (lumbar puncture,   fluids with               undiagnosed new   thoracentesis)   additives; closed               problem       treatment of               w/uncertain       fracture or               prognosis; acute       dislocation w/o               complicated injury       manipulation           High   One or more   Cardiovascular   Emergency major               chronic illness   imaging studies;   surgery,               w/server   cardiac   parenteral               exacerbation;   electrophysiological   controlled               acute or chronic   tests; diagnostic   substances; drug               illness or injuries   endoscopes;   therapy requiring               that pose threat to   discography   intensive               life or bodily       monitoring;               function; abrupt       decision not to               change in       resuscitate due to               neurological       poor prognosis;               status.       elective major                       surgery                       w/identified risk                       factors                    
The determined level according to the table above will be circled in the following table:
 
         [0000]    
       
         
               
               
               
               
               
             
           
               
                   
               
               
                   
                   
                 Low 
                 Moderate 
                 High 
               
               
                 MDM 
                 Straightforward 
                 Complexity 
                 Complexity 
                 Complexity 
               
               
                   
               
             
             
               
                 Risk 
                 Minimal 
                 Low 
                 Moderate 
                 high 
               
               
                   
               
             
          
         
       
     
         [0103]    After the risk complications have been assessed and a determined level has been provided each element of the medical decision-making is compiled in a summary decision-making table. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 Summary MDM Tabe 
               
             
          
           
               
                   
                   
                 Low 
                 Moderate 
                 High 
               
               
                 MDM 
                 Straightforward 
                 Complexity 
                 Complexity 
                 Complexity 
               
               
                   
               
               
                 Dx/Mgmt 
                 Minimal 
                 Limited 
                 Multiple 
                 extensive 
               
               
                 Data 
                 Min/none 
                 limited 
                 moderate 
                 extensive 
               
               
                 Risk 
                 minimal 
                 low 
                 moderate 
                 high 
               
               
                   
               
             
          
         
       
     
         [0104]    After we determine each element of medical decision making we compile the information in a Summary Decision Making Table and circle the elements found. After that the lowest level is crossed out and then pick the next highest. For example, here, the Data element is the lowest. We cross that out and determine the overall level of service with the remaining two. The level is Moderate Complexity. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
           
               
                   
               
               
                 Summary MDM Table 
               
             
          
           
               
                   
                   
                 Low 
                 Moderate 
                 High 
               
               
                 MDM 
                 Straightforward 
                 Complexity 
                 Complexity 
                 Complexity 
               
               
                   
               
               
                 Dx/Mgmt 
                 Minimal 
                 Limited 
                 Multiple 
                 extensive 
               
               
                 Data 
                 Min/none 
                 limited 
                 moderate 
                 extensive 
               
               
                 Risk 
                 minimal 
                 low 
                 moderate 
                 high 
               
               
                   
               
             
          
         
       
     
         [0105]    Lower levels may be crossed out and there may be a determination that moderate complex medical decision may be accompanied with the particular procedure. This will enable the coder to then identify codes that are appropriate for each of the procedures that are in these particular areas of medical service. By using this particular system to implement medical coding an individual may easily learn and acquire knowledge of codes associated with the various levels of determination after application of the above procedures. Going through this process allows an individual to grasp a better understanding of the medical coding system and to address medical codes as applied in practice. 
         [0106]    To accurately code the Evaluation and Management service, it is important to follow the steps with the particular procedure. For Evaluation and Management codes, the coder must take into consideration a number of different things. 
         [0000]    When coding E/M Evaluation and Management codes, you need to consider:
 
Where the service was provided?
 
What type of service was provided?
 
What was the patient&#39;s status?
 
How much of a medical history was taken?
 
How much of a medical examination was performed?
 
How complex of a medical decision was made?
 
That&#39;s a lot of information to keep in mind! This will enable the coder to then identify codes that are appropriate for each of the procedures that are in these particular areas of medical service. By using this particular system to implement medical coding, an individual may easily learn and acquire knowledge of codes associated with the various levels of determination after the application of the procedures above. Going through this process allows an individual to grasp a better understanding of the medical coding system and to address medical codes as applied in practice.