Examples of medical decision making

Q: Can you give examples of medical decision making to help me understand?

A:

Case #1: A 4-year-old presents with a red, wollen left upper lid (LUL), with increasing severity over the previous two days. He had an associated upper respiratory infection.

Assessment and Plan

Preseptal cellulitis LUL

Considered ordering comput­ed tomography or magnetic resonance imaging of the orbit but deferred that order since able to see full ocular motility. Discussion with pediatrician about Rocephin (ceftriaxone sodium) injection. Prescribed oral antibiotics for 10 days. Instructed patient’s mother to call if increased fever or swelling over the subsequent 24 hours.

For this case, here’s a breakdown of the medical decision making (MDM):

Diagnosis addressed: Moderate – One undiagnosed new prob­lem with uncertain prognosis

Data reviewed: Moderate – Independent historian and discussion of management with a pediatrician

Risk: Moderate - Prescription drug management

Overall MDM:Moderate – E/M code 99204 or 99214

Case #2: A patient had shingles on the right side of her face and, ultimately, in her right eye. She had severe pain and photopho­bia in the right eye.

Assessment and Plan

Zoster in the right eye

Prescription drug management with acyclovir and topical steroids. Follow-up in one week or sooner. Phone conversation about findings and treatment with primary care physician.

For this case, here’s a breakdown of the medical decision making.

Diagnosis addressed: High – Chronic illnesses with severe exacerbation, progression, or side effects of treatment

Data reviewed: Moderate – Discussion of management with external physician

Risk: Moderate – Prescription drug manage­ment

Overall MDM:Moderate – E/M code 99204 or 99214

Renee Dowling is a compliance auditor at Sansum Clinic, LLC, in Santa Barbara, California.