Medical Decision Making Scoring Systems

 Most use the Marshfield Clinic Type Audit Tool to Most use the Marshfield Marshfield Clinic Type Audit Tool to expand on the Documentation Guidelines 

 Not an official part of the DGs 

 Tool used to score the overall Medical Decision Making  components 

 Evaluates 3 components components: 

 Number of Diagnosis and Management Options 

 Amount and Complexity of Data 

 Risk

Medical Decision Making: Number of Diagnosis or Management Options

CPT® does  not distinguish between  new and established patients in the ED

 New problem no additional Work up Patient seen and discharged

 Patient Patient seen and discharged discharged 

 New problem with additional Work up 

 Admit, Transfer, OR, ….

Amount or Complexity of Data

 Review and/order clinical lab test 1 point Review and/order and/order clinical clinical lab test 1 point 

 Review and/order radiology test 1 point 

 Review and/order medicine test 1 point 

 Discussion of test results with performing physician 1 point

 Decision to obtain old records and/or history from someone other than the patient 1 point 11 someone someone other than the patient patient 1 point 

 Review and summarization of old records or obtaining history from someone else or discussion of case with another health provider 2 points 

 Independent visualization of image, tracing, or specimen 2 points