CASE.EDU:    HOME | DIRECTORIES | SEARCH

Department of Neurology
 

NEUROLOGY: CODING AND DOCUMENTATION:

Determination of the Level of Diagnosis &/or Management Options

The level of medical decision making depends on whether the patient has established or new problems; whether they are stable or worsening; and whether any further work-up is planned. The level of Diagnosis &/or Management Options is calculated by adding up points based on the table below. This is what auditors use to review your notes.

Does the patient have: NUMBER POINTS SCORE
Self-limited or minor problem (stable, improved or worsening) max = 2 1  
Established problem (stable, improved or resolving) any 1  
Established problem (inadequately controlled, worsening or failing to change) any 2  
New problem to you, no additional work up planned max = 3 3  
New problem to you, additional workup planned any 4  
    TOTAL:  

Once the total points are summed, the proper level can be determined from the table below:

Level of Diagnosis &/or Management Options Total Points
Minimal 1 Point
Limited 2 Points
Multiple 3 Points
Extensive ³ 4 Points

Examples
 

•  A patient with a stable neuropathy (1 point) comes in with new headaches. The headaches are c/w tension headaches and no workup is planned (3 points). The total points are 4 : Level-Extensive.

•  A patient with Parkinson's Disease fails to respond to Sinemet (2 points). He also has a history of degenerative disk disease which is unchanged (1 point). The total points are 3: Level-Multiple.

•  A patient with a stable seizure disorder (1 point) comes in with new facial numbness and an MRI is ordered (4 points). The total points are 5: Level-Extensive.