emergency medicine templates with prompts that support ama documentation requirements

The American Medical Association (AMA) rolled out new guidelines to determine the ED Professional Level of Service.

With these new guidelines, the Medical Decision Making (MDM) documentation is the key driver for coding.

History, Review of Systems and Physical Exam are medically appropriate, but no longer “count” in calculating professional level of service, as they did previously.

These changes have the potential to decrease level 5’s to level 4’s if charts lack supporting documentation consistent with the new guidelines

CD|Notes Updated MDM Section with Prompts Consistent With AMA Documentation Requirements:

Medical Decision Making:

I spoke with an independent historian: {spouse; parent; guardian; caregiver; EMS; police; witness; not applicable}

Illness addressed is: {acute; chronic; self-limited or minor; undiagnosed new problem/uncertain prognosis; threat to life or bodily functions; exacerbation, progression, or side effects of treatment}

Prescriptions written: {prescriptions written; none}

Medications given in ED: {medications given; none}

Data reviewed from external source: {labs; radiology studies; patient care notes; not applicable}

I discussed patient management with an external source: {primary care physician, consultant, hospitalist; social worker; detox counselor; power of attorney; lawyer; parole office; not applicable}

Surgery/ED Procedures: {describe procedure performed; minor with no risk factors; minor with risk factors; major with no risk factors; major with risk factors}

Diagnosis or treatment significantly limited by social determinants of health?: {Homelessness; unemployed; uninsured; explain; not applicable}

Reviewed risks/benefits of hospitalization vs. discharge: {yes-explain; not applicable}

sample MDM documentation with prompts consistent with AMA’s guidelines:

ACEP Coding/Reimbursement FAQ link:

Disclaimer:

CD|Notes templates have been developed by sources knowledgeable in their fields and are intended to assist clinicians with an efficient means to document a comprehensive note.   However, CD|Notes cannot guarantee that the information contained in the templates is in every respect complete or up to date.

The CD|Notes templates are provided "as is" without warranty of any kind, either express or implied, including, but not limited to, the implied warranties of merchantability and fitness for a particular purpose. Payment policies can vary from payer to payer. CD|Notes, its authors or editors assume no responsibility for, and expressly disclaim liability for, damages of any kind arising out of or relating to any use, non-use, interpretation of, or reliance on information contained or not contained within the templated notes. In no event shall CD|Notes be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information or material. Specific coding or payment related issues should be directed to the payer.