Version 20.16
Important Note about the Development of these Features It is important to note that the details of what “should” and “should not” count are evolving and the developments in OP can only align with what we know to be true at the time of development. We expect that there will be modifications to the enhancements as more is learned from both the industry and our practices. All coding recommendations are suggested based on information that can be tracked in OP. |
There are 3 elements of Medical Decision Making: Problems Addressed, Data Reviewed, and Risk of Complications. There are 4 levels of Medical Decision Making: Straightforward, Low, Moderate, and High. In order to qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded. After reviewing where and how each element is indicated in OP, review the definitions and some examples for each element.
Problems Addressed: Number and complexity of problems addressed
OP Can • Count the number of problems/diagnoses in the Assessment • Count if they are 1 of the Problem Status options if specified by the user at the template or Assessment level • Default the MDM element level in the Coding section of note to Minimal | OP Cannot • Determine if the acute problem is self-limited or minor vs Acute- uncomplicated • Determine if an acute injury is "complicated" • Determine if an acute new problem has an "uncertain prognosis" |
Where and How Problems Addressed are Indicated in OP (Click thumbnail to enlarge image)
| Problem Status in Encounter Templates Clinical tab > Encounter Templates | Problem Status in Assessment Section of Note Encounter Note > Assess/Plan | ||||
Use the Problem Status drop-down located in the Diagnosis section of the Encounter Note tab in the Encounter Template Editor to set the default Problem Status for the diagnosis. This can be changed in the Encounter.
| Use the Problem Status drop-down located in the Diagnosis section of the Assessment section of the Encounter Note to select the Problem Status for each diagnosis. If the Problem Status is already populated because it was set at the template level, the provider should verify it is appropriate to the Encounter and adjust if necessary.
|
Data Reviewed/Analyzed: Amount and/or complexity of data reviewed and analyzed
OP Can • Disregard the selection of "Self" for Independent Historian from the data review count. • Count direct lab interface (DTI) orders and in-house labs by counting each unique lab in a requisition separated by a semi-colon. • Count surveys reviewed on the date of the visit that do not carry their own CPT charge. • Count each lab marked reviewed today on the date of the visit that was not counted as an ordered lab for the visit. • Count each unique test ordered. Each order counts as a valid action. For example, if a provider orders 3 labs, then the provider has performed 3 actions.
Note: You cannot double-dip and count a test that you ordered when that test is being separately reported and the work of interpretation and report is under that code descriptor. Examples: Developmental testing (96112-96113), Spirometry (94010, 94060), and EKG (93000 or 93010). Some codes that do not include the terminology “interpretation and report” in the code descriptor: 84181, 84182, 85390, 86152, 86153, 88173, 88791, 88312, 88371, 88375, 89049. Further guidance: |
OP Cannot • Count paper copies of reports initialed. • Know which kind of scanned report someone is reviewing because users can label things any way they want. Providers are held accountable for their decision to label documents appropriately.
* By definition, these are created by the practice ** This would double-count what you already have in Surveys *** These are always outgoing |
Where and How Data Reviewed/Analyzed is Indicated in OP (Click thumbnail to enlarge image)
| Document Management | Visit Info section of Note | Couns/CoC section of Note | Diagnostic Tests |
Use the Mark Reviewed button. This now counts a re-review of the document if the date = today.
| Use the Independent Historian drop-down list of the patient's Family Contacts or the free-text field to document who is providing information to the provider. The person responsible for entering this information should be decided on by the Practice.
| • Use the Discussed with field to select a name from Address Book or the patient's Clinical Contacts. Documentation of the discussion must also be entered into the Coordination of Care field. • Use the Independent Interpretation of Tests checkbox to indicate such interpretation. Documentation of the interpretation must also be entered into the Coordination of Care field.  | Use the Reviewed Today * button to indicate that a historical result was reviewed on the date of the Encounter, given it is relevant to the patient's current visit/reason for seeking care. * Feature Development Notes: - As of 11/30, the decision to exclude labs previously reviewed by you or another provider in the practice was made by the AMA, and OP plans to deliver the ability to filter these out in a future release. |
Risk of Complications and/or Morbidity or Mortality of Patient Management
OP Can • Count Risk Assessment items eligible to be counted as Social Determinants of Health (SDOH) that are marked pertinent for today's visit. • Count when a provider issues a prescription with a linked NDC. The prescription needs to have one of the following statuses to be counted toward MDM:- SENT - PRINTED - FAXED - PICKED UP - CALLED - DELIVERED - MAILED - PENDING |
OP Cannot • Filter out ineligible OTC medications. The provider must decide whether or not to include an OTC medication when coding the Encounter. • Default to an element level of Risk. The user must select or perform requirements for Moderate Risk calculation. • Determine the complications of morbidity/mortality of patient management. For example, the decision to perform minor surgery and/or prescription management of chronic conditions. The provider must decide whether or not to adjust the Risk Level when coding the Encounter. • Support calculating Minimal, Low, and/or High Risk levels |
Where and How Risk of Complication is Indicated in OP (Click thumbnails to enlarge images)
Risk Assessment Editor | Risk Assessment in an Encounter | Assess/Plan |
Use the SDOH checkbox to mark Risk questions as eligible for SDoH. By default, Food Insecurity, Health Literacy, and Housing Insecurity are selected.  | Use the Pert (pertinent) checkbox to indicate which Risk Factors are pertinent to the visit.  | Use the Managing patient's medication checkbox located in the Plan section of the Encounter to document that prescriptions were created or managed on the date of the visit. |
Version 20.15
Important Note about the Development of these Features It is important to note that the details of what “should” and “should not” count are evolving and the developments in OP can only align with what we know to be true at the time of development. We expect that there will be modifications to the enhancements as more is learned from both the industry and our practices. All coding recommendations are suggested based on information that can be tracked in OP. |
There are 3 elements of Medical Decision Making: Problems Addressed, Data Reviewed, and Risk of Complications. There are 4 levels of Medical Decision Making: Straightforward, Low, Moderate, and High. In order to qualify for a particular level of MDM, two of the three elements for that level of MDM must be met or exceeded. After reviewing where and how each element is indicated in OP, review the definitions and some examples for each element.
Problems Addressed: Number and complexity of problems addressed
OP Can • Count the number of problems/diagnoses in the Assessment • Count if they are 1 of the following 8 categories if specified by the user at the template or Assessment level: -Acute-minor, Acute-uncomplicated, Acute-complicated, Acute-severe, Chronic-stable, Chronic-unstable/increased, Chronic-recurring, Chronic-severe • Default the MDM element level in the Coding section of note to Minimal | OP Cannot • Determine if the acute problem is self-limited or minor vs Acute- uncomplicated • Determine if an acute injury is "complicated" • Determine if an acute new problem has an "uncertain prognosis" |
Where and How Problems Addressed are Indicated in OP (Click thumbnail to enlarge image)
| Problem Status in Encounter Templates Clinical tab > Encounter Templates | Problem Status in Assessment Section of Note Encounter Note > Assess/Plan | ||||
Use the Problem Status drop-down located in the Diagnosis section of the Encounter Note tab in the Encounter Template Editor to set the default Problem Status for the diagnosis. This can be changed in the Encounter.
| Use the Problem Status drop-down located in the Diagnosis section of the Assessment section of the Encounter Note to select the Problem Status for each diagnosis. If the Problem Status is already populated because it was set at the template level, the provider should verify it is appropriate to the Encounter and adjust if necessary.
|
Data Reviewed/Analyzed: Amount and/or complexity of data reviewed and analyzed
OP Can • Disregard the selection of "Self" for Independent Historian from the data review count. • Count direct lab interface (DTI) orders and in-house labs by counting each unique lab in a requisition separated by a semi-colon. • Count surveys reviewed on the date of the visit that do not carry their own CPT charge. • Count each lab marked reviewed today on the date of the visit that was not counted as an ordered lab for the visit. • Count each unique test ordered. Each order counts as a valid action. For example, if a provider orders 3 labs, then the provider has performed 3 actions.
Note: You cannot double-dip and count a test that you ordered when that test is being separately reported and the work of interpretation and report is under that code descriptor. Examples: Developmental testing (96112-96113), Spirometry (94010, 94060), and EKG (93000 or 93010). Some codes that do not include the terminology “interpretation and report” in the code descriptor: 84181, 84182, 85390, 86152, 86153, 88173, 88791, 88312, 88371, 88375, 89049. Further guidance: |
OP Cannot • Count paper copies of reports initialed. • Know which kind of scanned report someone is reviewing because users can label things any way they want. Providers are held accountable for their decision to label documents appropriately.
* By definition, these are created by the practice ** This would double-count what you already have in Surveys *** These are always outgoing |
Where and How Data Reviewed/Analyzed is Indicated in OP (Click thumbnail to enlarge image)
| Document Management | Visit Info section of Note | Couns/CoC section of Note | Diagnostic Tests |
Use the Mark Reviewed button. This now counts a re-review of the document if the date = today.
| Use the Independent Historian drop-down list of the patient's Family Contacts or the free-text field to document who is providing information to the provider. The person responsible for entering this information should be decided on by the Practice.
| • Use the Discussed with field to select a name from Address Book or the patient's Clinical Contacts. Documentation of the discussion must also be entered into the Coordination of Care field. • Use the Independent Interpretation of Tests checkbox to indicate such interpretation. Documentation of the interpretation must also be entered into the Coordination of Care field. | Use the Reviewed Today * button to indicate that a historical result was reviewed on the date of the Encounter, given it is relevant to the patient's current visit/reason for seeking care. * Feature Development Notes: - As of 11/30, the decision to exclude labs previously reviewed by you or another provider in the practice was made by the AMA, and OP plans to deliver the ability to filter these out in a future release. |
Risk of Complications and/or Morbidity or Mortality of Patient Management
OP Can • Count Risk Assessment items eligible to be counted as Social Determinants of Health (SDOH) that are marked pertinent for today's visit. • Count when a provider issues a prescription with a linked NDC. The prescription needs to have one of the following statuses to be counted toward MDM:- SENT - PRINTED - FAXED - PICKED UP - CALLED - DELIVERED - MAILED - PENDING |
OP Cannot • Filter out ineligible OTC medications. The provider must decide whether or not to include an OTC medication when coding the Encounter. • Default to an element level of Risk. The user must select or perform requirements for Moderate Risk calculation. • Determine the complications of morbidity/mortality of patient management. For example, the decision to perform minor surgery and/or prescription management of chronic conditions. The provider must decide whether or not to adjust the Risk Level when coding the Encounter. • Support calculating Minimal, Low, and/or High Risk levels |
Where and How Risk of Complication is Indicated in OP (Click thumbnails to enlarge images)
Risk Assessment Editor | Risk Assessment in an Encounter | Assess/Plan |
Use the SDOH checkbox to mark Risk questions as eligible for SDoH. By default, Food Insecurity, Health Literacy, and Housing Insecurity are selected. | Use the Pert (pertinent) checkbox to indicate which Risk Factors are pertinent to the visit. | Use the Managing patient's medication checkbox located in the Plan section of the Encounter to document that prescriptions were created or managed on the date of the visit. |
