Data first. Select the data you reviewed for this patient.
Tests Ordered:
Each "test" is a unique item like a CBC, troponin, a CT scan, EKG,
etc.
Test results reviewed (excluding labs):
You don't get credit for "reviewing" labs — it's assumed that the
review is part of the ordering process — even if you're "interpreting"
the BUN/Cr ratio and suggesting pre-renal or a GI bleed.
You do get credit for reviewing imaging, EKGs, etc.
Prior external notes reviewed:
"External" notes are notes from outside your ED/hospital setting OR
outside your specialty. So it's not external if it's your ER colleague
you work with, but if it's a PCP or specialist at your hospital,
that's still "external." An ER doc working at an outside hospital is
also external.
Each note or study you review counts individually. So if you look at
the last progress note and their prior echo, that's 2 notes.
An independent historian is anyone that provides additional
information that the patient can't providie — that could be because
they were unconscious or altered, or they're demented, or they're too
young, or they know something the patient might not.
Examples could include EMS, a parent, a nurse at a SNF, the neighbor
who brought the patient in, etc.
It does not include interpreters.
Independent interpretation means you reviewed the test yourself —
independently — so for us that's mostly going to be imaging or an EKG.
Independent means that yes, someone else is going to do the final
read, but you're interpreting it yourself — for example, you're not
waiting 3 days for cardiology to read the EKG.
You cannot count EKG interpretation if you're separately billing for it (CPT 93010).
Most of the time for us this is a consult.
This does have to be a discussion — a back and forth exchange — not
just sending the chart to the PCP for followup.
"External physician" means outside of your specialty. No curbsiding
your colleague.
This could be calling Ortho for example to get outpatient followup, or
to review an XR or reduction with them — that's certainly included
here.
This can include other professionals that interface with patients/healthcare: lawyer, parole officer, case manager, etc.
Risk. We're talking risk of morbidity, mortality, or complications.
This is truly meant to be your clinical concern of the patient's risk
of badness — morbidity, mortality, complications.
A low chance of missing a subarachnoid can still be "high risk" and a
high chance of missing a bug bite can be "low risk."
The examples below are EXAMPLES ONLY and make a little more sense in
the outpatient world. Again, they are for guidance only.
I've bolded the really important ones for EM: social determinants of
health, prescription drug management, or parental controlled
substances.
You get credit for tests that you would normally do but are not
in line with the patient's goals of care.
Prescription drug management — this includes administering or prescribing medications during the ED visit or reviewing current medications and deciding to hold or continue them based on the problem
Decision regarding minor surgery with identified patient or procedure risk factors — minor procedures might be things like lac repairs, I&D, etc.
Decision regarding elective major surgery without identified patient
or procedure risk factors — major procedures could be fracture management, significant joint reductions, etc.
Diagnosis or treatment significantly limited by social
determinants of health — like food or housing insecurity, poverty, medical or English literacy, insurance status, unemployment, substance use
Parenteral controlled substances
Drug therapy requiring intensive monitoring for toxicity
Decision regarding elective major surgery with identified patient or
procedure risk factors - major procedures could be fracture management, significant joint reductions, etc.
Decision regarding emergency major surgery - major procedures could be fracture management, significant joint reductions, etc.
Decision regarding hospitalization or escalation of hospital-level
care
Decision not to resuscitate or to deescalate care because of poor
prognosis
Almost there! Time for number & complexity of problems.
As you'll see, problems considered is often acceptable even if the patient doesn't receive a particular final diagnosis. If you considered a pulmonary embolus but they ruled out with the PERC rule (and you document that) — you still consider their problem as complex as serious as a pulmonary embolism.
Minimal
This is probably going to be extremely rare in the ER — it truly
means self-limited — something that will go away on its own. Maybe a
bug bite?
Low
As above.
Stable means the problem/issue is at its baseline. It's controlled.
This does NOT mean hemodynamic stability. If they're in the ER,
they're probably not being evaluated for their "stable" low back
pain or "stable" hypertension.
Uncomplicated = "short-term problem with low risk of morbidity for
which treatment is considered and little to no risk of mortality
with treatment, and full recovery without functional impairment is
expected."
Again, you're probably not seeing "stable" acute illness. Maybe
they're clinically improving with their COVID but someone sent them
in to be checked on.
Probably something like "they're just sick enough to need the
hospital" — they're stable but they can't stop vomiting, or have a
social issue dictating their need for hospital care?
Moderate
We see this every day. Patient with X, and X is worse than it
normally is (see below as this sometimes requires admission and
therefore is a more serious problem).
As above; you're probably not seeing multiple well-controlled
chronic diseases in the ER.
This a huge one for us. This includes things in the differential
that are serious but are undiagnosed (and that they might not have
after your workup). From the guidelines: "A problem in the
differential diagnosis that represents a condition likely to result
in a high risk of morbidity without treatment."
Systemic symptoms with a high risk of morbidity without treatment.
Note: they specifically call out that having a fever or fatigue with
a minor illness wouldn't qualify here and should be "acute,
uncomplicated illness or injury."
An injury that requires treatment including evaluation of the body
systems not just directly impacted, or the injury is extensive, or
there are multiple treatment options or have associated morbidity.
High
This is our bread and butter. COPD or CHF that may require
admission, or at least aggressive treatment and "escalation of care"
— significant risk of morbidity.
Similar to above, but even sicker — a threat to life or body
function without treatment. Also, if the patient has symptoms of a
serious condition and it is "significantly probable" and that
condition poses a threat to life or body function, this also fits
into this category.
