Location
Severity
Timing
Modifying Factors
Associated Associated Signs and Symptoms Symptoms
Onset
Quality
Duration
Past Medical
Past Illnesses
Major Injuries
Surgical History
Hospitalizations
Immunizations
Feeding/Dietary
Family History
Health Status
Deaths
Hereditary Diseases
Social History
Drug, etoh , tobacco
Employment
Marital Status
Sexual History
Past Illnesses
Major Injuries
Surgical History
Hospitalizations
Immunizations
Feeding/Dietary
Health Status
Deaths
Hereditary Diseases
Drug, etoh , tobacco
Employment
Marital Status
Sexual History
There are 14 organ systems recognized by CMS:
Constitutional
Eyes
Ears, Nose, Mouth and Throat
Cardiovascular
Respiratory
Gastrointestinal
Musculoskeletal
Integumentary (skin and/or breast)
Neurologic
Psychiatric
Endocrine
Hematologic/Lymphatic
Allergic/Immunologic
CMS recognizes the following 14 systems as part of the physical exam:
Constitutional
Eyes
Ears, Nose, Mouth and Throat
Neck
Respiratory
Cardiovascular
Chest (Breasts)
Gastrointestinal
Genitourinary
Lymphatic
Musculoskeletal
Skin
Neurologic
Psychiatric
MDM complexity can be increased by documenting the following things as applicable
Discussing differentials
Review labs as it relates to the case
Independently review imaging
Note discussions with consultants
Note discussions of imaging/procedures with performing provider (radiology, GI, ENT, etc)
Order prescription medications
CMS MDM example.
Multiple possible diagnoses for patient’s chest pain considered. After reviewing the patient’s medical record, lab and radiology results and discussing the case with the patient’s PMD, doubt PE as pulse oximetry normal and no tachypnea or tachycardia. Dissection unlikely as presentation not consistent with the diagnosis. ACS unlikely as normal EKG and no risk factors. Combination of infiltrate on CXR, fever and cough make pneumonia most likely diagnosis. Moderate risk of complications. Will treat with antibiotics and admit.
Billing
Wound ballistics
Formulas
Body packing
Dermatologic nomenclature
Explosions
Heat wave
Sutures