What’s in your MDM?

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Angry Birds said:
62yoF PMH DM here w/ LLQ pn, n/v x3d. VSS. Nontoxic. CT, labs, urine - reviewed, c/w acute sigmoid diverticulitis w/o perf. Tolerating PO. Exit abdominal exam is benign. Appropriate for outpt abx. Understands return precautions. Informed of incidental findings [list what they are, or actually you can just put it in discharge instructions, which is better.]
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I think this is interesting.

A pt comes in complaining of LLQ abdominal pain, they are tender (so not benign), and CT shows diverticulitis. And for whatever reason they are discharged (because it often is.)

Writing "Exit abdominal exam is benign" is either 1) false because diverticulitis doesn't get better in a few hours, 2) true because they got a ton of narcotics, or 3) ... well I can't think of a three.

Yet we all do this. I write this, a ton of docs write this. The suggestion is that we are afraid to send people home with abd pain. What if they still had abd pain when we discharge them?

I think in reality what we want to show is that people aren't getting worse when they are discharged. Diverticulitis perforates 2% of the time regardless of what you do. So I wonder if we write "Abd exam not getting worse" would be just fine legally. We all know that the vast majority of what we do in a chart is to protect our behinds in court.
 
thegenius said:
I think this is interesting.

A pt comes in complaining of LLQ abdominal pain, they are tender (so not benign), and CT shows diverticulitis. And for whatever reason they are discharged (because it often is.)

Writing "Exit abdominal exam is benign" is either 1) false because diverticulitis doesn't get better in a few hours, 2) true because they got a ton of narcotics, or 3) ... well I can't think of a three.

Yet we all do this. I write this, a ton of docs write this. The suggestion is that we are afraid to send people home with abd pain. What if they still had abd pain when we discharge them?

I think in reality what we want to show is that people aren't getting worse when they are discharged. Diverticulitis perforates 2% of the time regardless of what you do. So I wonder if we write "Abd exam not getting worse" would be just fine legally. We all know that the vast majority of what we do in a chart is to protect our behinds in court.
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What I think he means is that the clinical exam, impression and diagnostics support "uncomplicated" diverticulitis. Diverticulitis, in the presence of diffuse peritoneal signs constitute "complicated" diverticulitis for me though that may not constitute a formal definition and I admit these because risk of complication increases exponentially.

Here's a snippet from UpToDate that I think summarizes recommendations nicely.

Criteria for inpatient treatment — Patients with acute diverticulitis should receive inpatient treatment if [16,18,21]:

●CT shows complicated diverticulitis defined by the presence of frank perforation (eg, free air under the diaphragm with or without extravasation of contrast or fluid), abscess, obstruction, or fistulization.

●CT shows uncomplicated diverticulitis but the patient has one or more of the following characteristics:

•Sepsis (see "Sepsis syndromes in adults: Epidemiology, definitions, clinical presentation, diagnosis, and prognosis", section on 'Definitions')

•Microperforation (eg, a few air bubbles just outside of colon, or confined to the pelvis)

•Immunosuppression (eg, poorly controlled diabetes mellitus, chronic high-dose corticosteroid use, use of other immunosuppressive agents, advanced HIV infection, B or T cell leukocyte deficiency)

•High fever (>102.5°F/39°C)

•Significant leukocytosis

•Severe abdominal pain or diffuse peritonitis

•Advanced age

•Significant comorbidities

•Intolerance of oral intake

•Noncompliance/unreliability for return visits/lack of support system

•Failed outpatient treatment


Although fever, leukocytosis, severe abdominal pain, or old age have not been found to be associated with failure of outpatient management [21], such patient characteristics should be taken into account as a part of the global assessment of the patient when deciding whether he/she should be treated as an in- or outpatient.

Criteria for outpatient treatment — Patients may be able to receive outpatient treatment for diverticulitis if they do not meet any of the criteria for inpatient treatment listed above. (See 'Criteria for inpatient treatment' above.)


I know diverticulitis is really not the point of your post but thought that was a nice summary.

I get what you're saying though.... and the answer is yes, most of us (if you're smart) are masters at defensive medicine and defensive documentation. Until the medicolegal landscape changes in this country, I'd encourage everyone to be extremely proficient at documenting defensively in the chart. I don't condone dishonesty, of course, merely comprehensive documentation and exams that supports your MDM and disposition without contradicting standard of care or prior documentation in the chart. Remember, jury trials are not made up of your peers but lay people who are having medicine and "appropriate medical documentation" explained to them by lawyers.
 
Devil's advocate. Let's say you documented "voluntary guarding" or "rebound" or "severe abdominal pain" at any point in your chart. Well, unless you document a repeat benign abdominal exam, the first thing a lawyer is going to do is latch onto any ssx indicating that the pt had "diffuse peritoneal signs", then he's going to find an expert witness to say that there is evidence in your chart of "diffuse peritonitis" and agree that standard of care is admission for all diverticulitis with frank peritonitis. He'll also testify that frank peritonitis does not improve during the course of an ED visit and that your exam was obviously flawed on the repeat evaluation. LOL... I'm not saying you wouldn't win that case, but see what I mean? Don't open a can of worms on yourself within your chart if you don't have to... merely because it's quasi EBM, hyper "accurate" to a fault or the "new" standard of care based on a couple of journal articles released in 2017 with an N of 5. You'll get yourself into trouble that way. Always document defensively, anticipating that an attorney might be reviewing your chart someday. It might mean taking a few more minutes to tidy things up or adding an additional line or two in our MDM to support disposition but it will pay off eventually. I hate saying that but hey...this is the world of medicine we all practice in these days. I didn't ask for it....
 
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Yup I hear ya man. I tend to write things like "Improved", or "pain decreased", stuff like that.

Have you ever seen a pt for the second time within a day or two? (the answer is yes.....lol)
They were seen for n/v, and the first discharge note says "tolerating PO and no pain" and they come back and say "why did they discharge me I wasn't any better!" LOL
 
edit.
realized I already posted what I was going to say above.
 
Angry Birds said:
I would split the difference between the two... I like TimesNewRoman's approach, but I would want a quick interpretation of the pertinent positives from the labs/imaging, so I'd change it to:

62yoF PMH DM here w/ LLQ pn, n/v x3d. VSS. Nontoxic. CT, labs, urine - reviewed, c/w acute sigmoid diverticulitis w/o perf. Tolerating PO. Exit abdominal exam is benign. Appropriate for outpt abx. Understands return precautions. Informed of incidental findings [list what they are, or actually you can just put it in discharge instructions, which is better.]

I might fatten it out a bit more, but I think in between your two MDM's... Reason is that I think the MDM should stand alone so that another ER doctor can read it when the patient comes back and can know everything he/she needs to know. I think MDM is the only important part of a chart from that standpoint. The rest is for coding and legal reasons.
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I don’t think you gain anything by explicitly restating the imaging findings. The MDM is your thought process, simply stating things that are obvious doesn’t add anything or show any more thought than referencing them does. Now, there are certainly times I write much more, go into great detail on my findings/treatment course and innumerate my return precautions - As an example, I’ll macro out early appy return precautions or why I’m sending someone home with only one trop - but simple diverticulitis with a CT scan isn’t one of them. Heck, I’d write a lot more if I didn’t get the CT, but you have it. If you have a 75yo come in with productive cough, fever, rigors and new o2 requirement who has a wbc of 17 and focal infiltrate on CXR that you’re admitting, you don’t need more than a sentence - it’s obvious, billable and defensible. If you have an appy on CT and admit to surgery, same thing. It’s the marginal or nebulous who you’re sending home who need better documentation, or the complaints that are high risk.
 
You would be better off if you don't write anything abnormal on the exam if you send the patient home. Also putting more stuff on the chart doesn't help you. It is not like you get to read everything in front of a jury. It's not a criminal case usually and the plaintiff wins 2/3 of medmal cases you would be better off just not practicing in litigious states and ordering defensively rather than charting defensively.
 
Brigade4Radiant said:
You would be better off if you don't write anything abnormal on the exam if you send the patient home. Also putting more stuff on the chart doesn't help you. It is not like you get to read everything in front of a jury. It's not a criminal case usually and the plaintiff wins 2/3 of medmal cases you would be better off just not practicing in litigious states and ordering defensively rather than charting defensively.
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Defendant (doc) wins 5/6 of malpractice actions.
 
turkeyjerky said:
I think most of us would consider every settlement a loss as well though.
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Apollyon said:
That is completely true, and still a sad f'n indictment of a flawed system, but at least it's not as bad as it could be.
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It's a loss for sure.
A loss of time.
A loss of peace.
A loss of face.
A loss of vindication.
A loss of self-esteem.

I went thru this recently.
Settled for 8 million.
Initial demand was 26 million.
Everyone in that room audibly scoffed when that number was thrown out by plaintiff's counsel, because they knew it was bull****.
Even I had to stifle myself.

Now, I just don't give an eff anymore.
I'll post about it soon.
Probably not until after the holidays.
 
RustedFox said:
It's a loss for sure.
A loss of time.
A loss of peace.
A loss of face.
A loss of vindication.
A loss of self-esteem.

I went thru this recently.
Settled for 8 million.
Initial demand was 26 million.
Everyone in that room audibly scoffed when that number was thrown out by plaintiff's counsel, because they knew it was bull****.
Even I had to stifle myself.

Now, I just don't give an eff anymore.
I'll post about it soon.
Probably not until after the holidays.
Click to expand...

Sorry to hear, man. Curious as to what state you're in / caps / vague idea as to what that was all about whenever you're up to it, as I'm sure others are too.
 
Veil said:
Sorry to hear, man. Curious as to what state you're in / caps / vague idea as to what that was all about whenever you're up to it, as I'm sure others are too.
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GonnaBeADoc2222 said:
8 million?! wtf?! Is that in excess of your policy?
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Florida.
Yes.
Didn't pay a dime out of pocket, but wasted plenty of time.
Caps are a nebulous thing. I've learned that they really don't matter. Nor does a "three-strikes law". Nor does a statute of limitations.
On the whole, my attitude has gone from "OMG chart it all and multiple times and have it make sense and hold your breath..." - to - "I'm so bad, baby - I don't care."



 
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RustedFox said:
Florida.
Yes.
Didn't pay a dime out of pocket, but wasted plenty of time.
Caps are a nebulous thing. I've learned that they really don't matter. Nor does a "three-strikes law". Nor does a statute of limitations.
On the whole, my attitude has gone from "OMG chart it all and multiple times and have it make sense and hold your breath..." - to - "I'm so bad, baby - I don't care."



Click to expand...


Pending appeal to get below your policy limit type thing?
 
KGflyboy said:
Can someone give their example of a chest pain discharge mdm?
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Patient presented for eval of chest pain. EKG reassuring. CXR WNL. Serial troponins negative. Low risk for ACS by HEART score. No concern for PE or dissection. Patient discharged home with outpatient followup and return precautions.
 
Mine is something like this.

The patient presented with x. Their initial vitals revealed y (forces me to re-check vitals on every patient). The differential was z (just list a few sometimes). We did so and so intervention and so and so diagnostic tests which showed ____. Then I explain disposition and state that we discussed return precautions/follow-up if they were discharged.

E.G.

57-year-old female who presented with chest pain. Initial vitals were significant for tachycardia which later normalized. The differential included ACS as well as other cardiopulmonary pathology. EKG and CXR were unremarkable. D-dimer and troponin were both negative. Doubt PE or dissection at this time. The patient was given ASA and nitro with improvement in pain. Heart score is 5 and the patient will be admitted after discussion with the medicine service/PCP etc.
 
CP with HEART < 3 and risk stratified as “low risk” for ACS. No high risk features. Neg trop delta. EKG non worrisome. XR neg. PERC neg. HPI suggests non cardiac, non emergent etiologies. Clinical exam consistent with chest wall syndrome. Supportive care and f/u PCP in 3-5 days. Stern ED return precautions discussed.
 
EKG neg, trop neg. PERC neg. HEART score 1. Pt low risk for chest pain. D/C home and f/u with PCP. Return for worsening symptoms, or for any other problems or concerns.
 
BoardingDoc said:
Patient presented for eval of chest pain. EKG reassuring. CXR WNL. Serial troponins negative. Low risk for ACS by HEART score. No concern for PE or dissection. Patient discharged home with outpatient followup and return precautions.
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This, but also specifically with chest pain, I emphasize that follow up with a cardiologist within 48-72 hours for further outpatient risk stratification for underlying CAD (such as stress test) has been recommended with the strongest terms. The caveat of HEART score is its only powered to assess for risk of MACE within 60 days. Patients can have undiagnosed substantial underlying non-occlusive CAD (despite low risk HEART score) which is a risk factor for subsequent cardiac event at some point in the near future.

Yes I recognized stress tests are imperfect (saw a STEMI from a patient in the cafeteria who had just completed a literally negative stress MPI outpatient at the hospital 15 minutes before). But at that point it is now the cardiologist's decision that the patient did not get a cath and not you.
 
SpacemanSpifff said:
From a billing standpoint, how do you ensure that you meet the requirements for a level 5 in regards to the MDM? I've been told/read a number of variable requirements. ALiEM had a good post (ED Charting and Coding: Medical Decision Making (MDM)), but can practicing folks weigh in on how this compares to their experience with billing in the real world?
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You hopefully have a checkbox or something elsewhere that lets you say you independently viewed imaging or the patient's EKG. Check that. If you have ordered 2 out of 3 of the following: EKG, XR, Labs and you have commented on them, you're done.

E.g.
Box checked next to the CXR and I write in: No acute intrathoracic process
MDM: Patient presented with cough. VSS. No respiratory distress. No leukocytosis, CXR WNL. DC home with return instructions.
Dx: Viral syndrome

Now, this viral syndrome patient isn't going to get me to lvl 5, but the MDM elements to meet the lvl 5 criteria are there.

Same guy gets admitted:
CXR: LLL PNA.
MDM: patient presented with cough. Hypoxic to 80s on RA. Stable on 2L NC. +Leukocytosis and opacity on CXR suggest PNA. Abx. Admit.
Dx: PNA, hypoxic respiratory failure, leukocytosis

Lvl 5 chart.
 
SpacemanSpifff said:
From a billing standpoint, how do you ensure that you meet the requirements for a level 5 in regards to the MDM? I've been told/read a number of variable requirements. ALiEM had a good post (ED Charting and Coding: Medical Decision Making (MDM)), but can practicing folks weigh in on how this compares to their experience with billing in the real world?
Click to expand...

It helps if you have an EMR that will give you a visual indicator as to whether you have included enough components for level 5 chart. Most do these days. As a rule of thumb I usually chart everything as a level 5 regardless of whether the coders code it out to a 4 or a 3.

Oh sorry, misread. As for MDM, just familiarize yourself with the requisite components and complexity requirements. The AliEM link is a good review. Most MDM have subsections to help you convey complexity and obtain additional points. Reviewing labs, interpreting labs and imaging, listing ddx, reviewing documents, identifying critical values and conveying risk and severity as well as life saving or critical interventions are all important. My MDMs usually have everything “checked” in Cerner followed by a succinct, brief few lines regarding treatment course and my thought process.

Most CMGs will have coders reach out to you if you are routinely missing key items causing your charts to be down coded.
 
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If you're still in residency, I think it's great that you're taking a keen interest in coding/billing. If you can get facile at maximizing you're billing, it will go a long ways towards helping you hit the ground running after residency and "pleasing your masters", as well as maximizing your paycheck assuming you are operating in a semi RVU based practice.
 
thegenius said:
I think this is interesting.

A pt comes in complaining of LLQ abdominal pain, they are tender (so not benign), and CT shows diverticulitis. And for whatever reason they are discharged (because it often is.)

Writing "Exit abdominal exam is benign" is either 1) false because diverticulitis doesn't get better in a few hours, 2) true because they got a ton of narcotics, or 3) ... well I can't think of a three.

Yet we all do this. I write this, a ton of docs write this. The suggestion is that we are afraid to send people home with abd pain. What if they still had abd pain when we discharge them?

I think in reality what we want to show is that people aren't getting worse when they are discharged. Diverticulitis perforates 2% of the time regardless of what you do. So I wonder if we write "Abd exam not getting worse" would be just fine legally. We all know that the vast majority of what we do in a chart is to protect our behinds in court.
Click to expand...

 
Angry Birds said:
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tenor.gif
 
Do you all consider discharge instructions as essentially part of your chart = defensible medicine? Would documenting "discharge instructions provided" in your actual note be enough in court if the written instructions had the necessary things such as returning to ED for fevers, PO intolerance, worsening pain (in the theoretical case of diverticulitis)?
 
Renaissance Man said:
Do you all consider discharge instructions as essentially part of your chart = defensible medicine? Would documenting "discharge instructions provided" in your actual note be enough in court if the written instructions had the necessary things such as returning to ED for fevers, PO intolerance, worsening pain (in the theoretical case of diverticulitis)?
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Sadly, my understanding is that patients are not held liable to read their discharge instructions.
 
TimesNewRoman said:
Sadly, my understanding is that patients are not held liable to read their discharge instructions.
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Which is laughable, considering they sign them.

Our system has a small area where the doc free texts in instructions, and the nurses are supposed to read these off to the patients at the time of discharge. Then in addition there's a large attachment of general information. I consider the first to be part of the chart.

I wonder about the true necessity of documenting "discussed discharge instructions". I usually do, although I never bother documenting "discussed the need to return for worsening pain, fever, etc..." Since this is already in the dc instructions.

If I got sued and this came up, I would say that it was part of my usual and customary practice to do do with every patient I saw, which in addition to being legally viable is also true.
 
In Epic the discharge instructions are typed in and become part of the after-visit summary, which we print and hand to patients. I would imagine this counts as part of the medical record? Becoming an attending in 6 months and trying to figure out how to maximize efficiency in charts but still cover my own ass.
 
I often write things in the discharge summary "If you are not getting better after a week, please see your doctor for further evaluation" and I don't write "return to the ED". I write that for things that don't result in sudden death or instant morbidity.

I don't want the streptococcal pharyngitis coming back to my ER in 2 days if they are not getting better.

I figure...I have to deal with them if they show up anyway. So if they show up, I'll deal with it.
 
I have a cute little phrase I put in everyone's DCIs that says to follow up with PCP in a week and come back to the ED at any time for any concern basically. It's stupid not too and in no way harms you. Regarding the follow up, c'mon, they were seen in the ED for what they thought was a 'life threatening condition', they should follow up with their PCP. People who come to the ED for stupid things tend not read instructions anyways, so it may not be 100% defensible but I think it buffs the chart a little bit.
 
SamtheWise said:
I have a cute little phrase I put in everyone's DCIs that says to follow up with PCP in a week and come back to the ED at any time for any concern basically. It's stupid not too and in no way harms you. Regarding the follow up, c'mon, they were seen in the ED for what they thought was a 'life threatening condition', they should follow up with their PCP. People who come to the ED for stupid things tend not read instructions anyways, so it may not be 100% defensible but I think it buffs the chart a little bit.
Click to expand...

So what happens if we just write "follow up with PCP in a week" and don't put that nonsense in about coming back for basically any reason? Legally that is.
 
I thought reviving this thread was the best place for my question. I just started using EPIC again after....sheesh, probably 7 or 8 years. I noticed that the DDX is not anywhere as it is in Cerner. Cerner will typically list a few appropriate DDX based on the chief complaint that you can choose to click or not and therefore obtain what I've always understood as additional points for medical complexity. I notice that EPIC doesn't have a DDX anywhere to be found. However, they certainly have plenty of check boxes on the MDM page to allow you to indicate the level of complexity. Are you guys actually listing all your DDX in your MDM when using EPIC or are you skipping it and including it in say...your MDM as you dictate or somewhere else altogether? I've noticed some of my colleagues don't put a DDX at all.
 
Not sure if this is the right way, but the medicolegal specialist attending of mine in residency said it was best to not put a ddx because it gives away what you weren’t thinking of when you miss something. Instead said that to pull your orders in bc they show your ddx without specifically saying it.
 
Backpack234 said:
Not sure if this is the right way, but the medicolegal specialist attending of mine in residency said it was best to not put a ddx because it gives away what you weren’t thinking of when you miss something. Instead said that to pull your orders in bc they show your ddx without specifically saying it.
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I have the same opinion. If you say "Doubt PE" and then the patient has a PE, you've given the lawyer a noose to hang you with.

I find I write very little MDM on admitted patients, but a lot more on discharged ones.
 
RustedFox said:
It's a loss for sure.
A loss of time.
A loss of peace.
A loss of face.
A loss of vindication.
A loss of self-esteem.

I went thru this recently.
Settled for 8 million.
Initial demand was 26 million.
Everyone in that room audibly scoffed when that number was thrown out by plaintiff's counsel, because they knew it was bull****.
Even I had to stifle myself.

Now, I just don't give an eff anymore.
I'll post about it soon.
Probably not until after the holidays.
Click to expand...
+2 years later, still waiting, brother!
 
GeneralVeers said:
I have the same opinion. If you say "Doubt PE" and then the patient has a PE, you've given the lawyer a noose to hang you with.

I find I write very little MDM on admitted patients, but a lot more on discharged ones.
Click to expand...
Seems to be different opinions on this. Some say “clinically not consistent with PE” is better than not mentioning. Your defense could be “I thought about it and decided it wasn’t what was going on.” I have had “medicolegal experienced docs” swear up and down on both sides that they are correct. Either someone is wrong or there’s no right answer.
 
jw3600 said:
Seems to be different opinions on this. Some say “clinically not consistent with PE” is better than not mentioning. Your defense could be “I thought about it and decided it wasn’t what was going on.” I have had “medicolegal experienced docs” swear up and down on both sides that they are correct. Either someone is wrong or there’s no right answer.
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I document what I thought, why I thought about it and that it wasn't worth pursuing further. It might be the wrong approach, but I'm willing to stand behind it and fight if it comes to that! ...or maybe settle out of court if advised to by an attorney!
 
A clinically average doc with a negative test on his own chart, beats the clinically superior doc who didn't need a test but missed a diagnosis, every time. If you're thinking enough about something to write in that chart that your patient doesn't have it, leave a chart with proof. Don't leave a sentence that is the equivalent of, "I missed it and they died. Do I get brownie points for thinking about it?"

No one cares how clinically skilled you might be when you leave charts listing the diagnoses you were too smart to need tests for, but missed.
 
Groove said:
I thought reviving this thread was the best place for my question. I just started using EPIC again after....sheesh, probably 7 or 8 years. I noticed that the DDX is not anywhere as it is in Cerner. Cerner will typically list a few appropriate DDX based on the chief complaint that you can choose to click or not and therefore obtain what I've always understood as additional points for medical complexity. I notice that EPIC doesn't have a DDX anywhere to be found. However, they certainly have plenty of check boxes on the MDM page to allow you to indicate the level of complexity. Are you guys actually listing all your DDX in your MDM when using EPIC or are you skipping it and including it in say...your MDM as you dictate or somewhere else altogether? I've noticed some of my colleagues don't put a DDX at all.
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That has more to do with your build of Epic. At the places where I work, Cerner doesn't suggest anything and Epic does. Either way, I tend to dictate my top 5-8 and then indicate that it was just a partial list of the differential using dragon. Adding a DDX of at least 5 increased the complexity for some coders and is less likely to get down coded.
 
Birdstrike said:
A clinically average doc with a negative test on his own chart, beats the clinically superior doc who didn't need a test but missed a diagnosis, every time. If you're thinking enough about something to write in that chart that your patient doesn't have it, leave a chart with proof. Don't leave a sentence that is the equivalent of, "I missed it and they died. Do I get brownie points for thinking about it?"

No one cares how clinically skilled you might be when you leave charts listing the diagnoses you were too smart to need tests for, but missed.
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You must order a lot of CTAs then.
 
Birdstrike said:
A clinically average doc with a negative test on his own chart, beats the clinically superior doc who didn't need a test but missed a diagnosis, every time. If you're thinking enough about something to write in that chart that your patient doesn't have it, leave a chart with proof. Don't leave a sentence that is the equivalent of, "I missed it and they died. Do I get brownie points for thinking about it?"

No one cares how clinically skilled you might be when you leave charts listing the diagnoses you were too smart to need tests for, but missed.
Click to expand...
I agree regarding testing versus clinical acumen... which means I order more d-dimers than I used to do and often cite medical decision making rules (PERC, HEART score, etc)... However I think there still is a role for documenting thought processes and clinical judgement.
 
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