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
