1. UCSF Clinical Enterprise Compliance Program CECP Education Series Wanda T. Ziemba MFA RHIT CHCO CHCC CHC CPC Associate Compliance Officer & Clinical Enterprise Compliance Program Educator

2. Our Last Cruise … June 19 – Cruising Down the Alimentary Canal – Already Traversed July 17 – Beauty Is Skin Deep – Been There, Done That August 21 – Getting to Know the Ship’s Doctor

3. If you see this doctor, you’re on the wrong Enterprise …

4. Third “Port” of Call: The Ship Doctor and E&Ms Medical Decision Making –Type of Problem –Data –Risk History of Present Illness –HPI –ROS –PFSHx Physical Examination –1995 and 1997 guidelines

5. Medical Decision Making Chief Complaint Type of Problem –Self-Limited, Minor, 1pt (Max 2) –Est, Improved, Stable, 1pt –Est, Worsening, 2pts –New, No W/Up or Plan, 3 pts –New, W/Up & Plan, 4 pts

6. Medical Decision Making (cont.) Amount/Type of Data –Rev/Order Clinical Labs, 1 pt (max 1) –Rev/Order Imaging Studies, 1 pt (max 1) –Rev/Order Medical Diagnostics, 1 pt (max 1) –Discuss to Obtain Old Records, 1 pt –Discuss Results w/performing MD, 1 pt –Rev/Summ Old Records, 2 pts –Independent Rev, Tracing, Image, 2 pts

7. Medical Decision Making (cont.) Risk Table –Minimal/Minor –Low –Moderate –High Time Dominated –Total time/Counseling Time

8. Bingo #1: MDM New onset sexually transmitted disease, likely chlamydia Zithromax prescribed 500mg QD x 3 days Send for range of motion study under x-ray, right shoulder Refer to Cardiology for evaluation Total time: 30 minutes, 20 minutes of which was spent discussing safe sex while on cruise ships

9. And the winner is … Type of Problem: New, w/up & plan (4 pts) Amount/Type of Data: 1 pt Risk: moderate Equals: Moderate MDM

10. History HPI –Location – Modifying Factors –Quality – Timing –Severity – Context –Duration – Associated signs/symptoms

11. History (cont.) Review of Systems –Constitutional –Eye –ENMT –Cardiac –Respiratory –GI –Musculoskeletal –Integ/Breast –Neuro –Psych –Endocrine –Heme/Lymph –Allergy/Immunologic

12. History (cont.) PFSHx –Past Medical History –Family History –Social History

13. History: What Level? Focused –CC –HPI: 1-3 Expanded –CC –HPI: 1-3 –ROS: 1 pertinent Detailed –CC –HPI: 4+ –ROS: 2-9 –PFSHx: 1 Comprehensive –CC –HPI: 4+ –ROS: 10+ –PFSHx: 2-3 (3-=N,C)

14. Bingo #2: History 25 m dilated & hypertrophic CM w/ mild MR, hyperthyroidism Concerns re: STDs; contact 1 wk ago, irritation, burning on urination, OTC tinactin, no Δ No D/C, partner x 1 w/yeast infx, Ǿ IVD/Tattoos – energy level Ǿ Δ Ǿ CP, Ǿ CHF Sx’s, Ǿ palps ↑weight 5 lbs

15. Did you win? CCHPIROSPFSHxLevel Genital irritation Duration; context; assoc. s&s; modifying factors Constitutional; cardiovascular Partner w/yeast infx; Dilated & hypertrophic CM; mild MR; hyperthyroidism 4 HPI2 ROS2 PFSHxDetailed

16. Physical Examination 1995 and 1997 –Focused 97: 1-5 elements 95: 1 BA/OS –Expanded 97: 6 elements 95: 2-7 BA/OS –Detailed 97: 2 bullets for 6 BA or 12 bullets in 2 or more BA 95: 2-7 BA/OS Detailed –Comprehensive: 97: All elements 95: 8+ OS

17. Bingo #3: PE The patient is a 25 year old white male, alert & orient x 3, cooperative and in NAD. VS: 110/70, 60, 5’9”, 179 lbs AT NC PERRLA EOMI Neck Ǿ LAD Ǿ TM PMI ND S1 S2 (↑ A2) HS nml apex CTAB no retractions R shoulder notable >> larger L shoulder? Ǿ C/C/E nml pulse + foreskin, Ф irritation Ф discharge Ǿ no mass test Ф hernia

18. Who won this time? BA/OS19951997Comment Cons12 GA & VS (when at least 3) Eye11 Pupils & iris Head1 Under MS in 1997 guidelines ENMT11 TM CV14 Auscultation, palpation, edema, pulses Resp12 Auscultation & effort Ext2 Not in 1997 guidelines MS3 Inspection/palpation 3 areas Lymph11 Cervical GU13 Penis, testicles, hernia Psych12 Mood & affect, orientation Neuro11 EOMI – Cranial nerves

19. What’s the overall code? MDM: Moderate History: Detailed PE: Comprehensive Time: 30 minutes (if using time) 99203

20. Questions?