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SELECT PROVIDER TYPE
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Medical (MD/DO/APRN/PA)
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Therapy (LPC/LAC/LMFT/LCSW/LMSW/LPE/LCP)
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PLAN OF CARE
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HISTORY, RECORDS, LABS REVIEWED
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MED INTERVENTIONS / CHANGES
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REVIEWED RISK/BENEFITS/SIDE EFFECTS
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PSYCOTHERAPY INTERVENTIONS
• • •
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LAB ORDERS
• • •
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DIAGNOSTIC ORDERS
• • •
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EXTENDED RECOMMENDATIONS
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Diet
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Diet Comments
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PT Recommendations
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PT Recommendation Comments
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Education
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Education Comments
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Referrals
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Referral Comments
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ASBN / SUBSTANCE ABUSE EVALUATION RECOMMENDATIONS AND REQUIREMENTS
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Patient showed valid picture ID?
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Patient brought ASBN letter?
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Reviewed past Dx and Tx Response?
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Collateral Information Obtained?
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Collateral Contact (Name, Number, Relationship to Patient)
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Collateral Information Obtained (free-txt)
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Current Status of Substance Use / Abuse (free-txt)
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Current Psychological Status (free-txt)
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Clear to practice without restrictions?
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Restrictions Recommended (free-txt)
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Additional Recommendations for Follow Up / Treatment (free-txt)
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FOLLOW UP
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MEDICAL DECISION MAKING
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SUM OF PROBLEM POINTS => COMPLEXITY
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DISPLAY GUIDES
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4 pts/new with work-up planned, 3 pts/new, 2 pts/old uncontrolled, 1 pt/old stable (4 max)
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SUM OF DATA POINTS => COMPLEXITY
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DATA POINT GUIDE
• • •
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MAX RISK LEVEL => COMPLEXITY
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MAX RISK LEVEL GUIDE
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SELECT YOUR MDM = THE 2ND HIGHEST COMPLEXITY LISTED ABOVE
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STRAIGHTFORWARD MDM
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LOW COMPLEXITY MDM
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MODERATE COMPLEXITY MDM
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HIGH COMPLEXITY MDM
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CHOOSE FROM THE BELOW OPTIONS TO ASSIGN YOUR CODE
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ARKANSAS STATE BOARD OF NURSING EVALUATION
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LOW MDM & COMP HX & DET EXAM -99203
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STANDARD PSYCH EVAL -90792 (only choose if you DID NOT provide therapy-add-on)
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Did you document 3 vital signs with your exam AND a 10pt ROS with PMFSH?
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MOD MDM & COMP HX & COMP EXAM -99204
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HIGH MDM & COMP HX & COMP EXAM -99205
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STRAIGHTFORWARD MDM & PF HX / PF EXAM -99212
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LOW MDM & EPF HX / EPF EXAM -99213
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MODERATE MDM & DET HX / DET EXAM -99214
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Did you document 3 vital signs with your exam OR a 10pt ROS AND PMFSH?
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HIGH MDM & COMP HX / COMP EXAM-99215
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ADDITIONAL PROVISIONS / ITEMS REVIEWED
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MED MGMT POLICY REVIEWED
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GENERAL INSTRUCTIONS REVIEWED
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DISCHARGE CRITERIA REVIEWED
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