Desktop Coding Grid

- Medicl, stabl€y' OTC meds

improving t@tfiing tr@tllqt x I (not @ntinuous) Admit/tramfer to rcn-monitorcd bed, OR, Admit/transfer b non-m@itorcd bed. o&
* Comdications or new No ancillary t6t sptrial trstment ar€, w/o rcl*up spedal treatrnent a€, with wlGp
prcblfl requiring Catheteriation (foley or in & out cth) (by clinician or nurre) fc:
ancillaries or ilo meds in ED , IncontiMe, or AbdofiriGl q flank pain with: Agitated, @mbative q violeff pauent who reic D.l/ Iv Auvan,
fredications, @de to - Urine sample, or - lntmal pdvic qafi, 4r Gsdon, or HaHol and/q ctraints
appropriate hvd of No pEcripu@s d Urine output m€surement, or - Rectal qam, or
sflice - Flushing Foley @thetet - wb*up Criti@l @rc scenariG/managmst optiffi (Vo CC time) srch asl
- Surgical, stabl4 Return visit to sme ED - Chst tube
improving fq sch€duled/rep€t It4 Consuft (qduding psydr) ln ED tr dcumqted phoile Gll B@Hing tr€tmsts x 2 or > tr ontinurc d Central line
* within global period or Iv medietiffi - Chemi@l Grdio version
- No Charge Digital disimpactis (by clioician or nu6e) chd pain, palpit Uohs widr workup, w/o 6rdi.c enzym€ - CPR throughout visit
* Comdications/ vlsual acuity - ET Intubation
rc6ening; requiring - without slit lamp or stain Ensa (inc. FleLs) EKG - Gastric hvag€ for rerd6e or GI bleed
m€di@tions, ancillaris - Lumbar puncture
or prscrisions - ade Enminati(x, with 1of the follwing: FE€twed fmur / hip/ pdvis d Thotrtrtesis
b appropriate lryd of d B@st, or . TPA
sryice based on payer - Eye qam with slit lamp or flrcKein stain, or H€d Injury with neurclogi€l signs/symptqrs
requiremenb - Extemal gsitalia, or EKG wiln Cairtia En:frc
- Pdvk sm, Vo abdominal pain, or Lab6 x 4
Suturemwal - Redd, Vo abdominal pain, or Chst pain, palpitatim, abdminal pair. shqtn6 of b@th,
- Repert qam by dinician, or tab6 and x-Bys: syr@pe/Er syn@pe wlttr wqtup indudlng I of:
- 3 BAy'OS with noo enm as follows: d3labs+1x-ray - Cardiac enzymes or
* CN 2-12, tr CN nmal, or - D-Dimer
* GCS, or Pediatric Trauma ScoE, or l,ledications & lnfusiqs:
* 3 of the following: ffimd6; crebellar findings, @rdinatim, DTR, - IM/SQ @ntolled x 1 Chst abdomiml pain, palpitatiffi q shortre of b@th
EOM intad, "neck supple", odentation, PERLA, reflqes, Hsation, - IM/SQ x 2 non<ont'olled, same or diffffint meds with 3 dthe follNlng:
non-fo(al em, Nqus citsia - IM/SQ mediGtion with 1 of the following: - B@thing t@tm€nts x 2 or > or @ntinuous
* B@tlting tr€tment, or - 3 ancillaries
* tab, or - History obtained frcm another rcure
Fetal hert toG (FHf) * PO, eye, @r, r<tal mediGtion, intEnasl, or - IV fluids
* x{dy - IV or IM/SQ medictions
Fss > 100.5 F a 38C, indudiru history of d Mluids i Speial study x 1
- IV l4€diGtion:
labs, l-3, ind. aqqh€lc flu ff nasl swab. eyq thut q * 1 otolled, or fd 6pe 6 qime (by clinician)
wndetturc(s) * 1-2 non{ontrclled (eme or diffsqt meds)
. 4 T6t ard I d tlre follwkig:
Medietiffi, t of tlle foliling: Irlod@te s€dauon - ABG, or CBG, oT VBG
- IM / SQ x 1 medi@tion, nmrdtrclled. or - Blood cultur€(s), or
d Po, eye, @rr Etd, bpkal, olc dEds (any numbd), ituaGsal, or k€gmnt pt, with: d Brsthing treatment x 2 or > or @tinuous,
- Pr€ri$ion on dishalge, or meds to take home - Mireriagq spontan@us abortion d Clnsuft, or
d Ljterirc monitoring (in ED or L&D) , 24 weeks or gr€tq - History obtained from anothtr $ure
MvA (wtt|lln past 7 days) w/o wq* up - IVfluids and IV/ IM / SQ med(s)
Mlat.rt pt wlth psydr or sodal oGUh
t{€edle StickrBody Fluid Expcurc (cmplaint/prot@Uparel) l,lediGtions & inf6lons:
Rape with rc foHsic evldence c{illctim (by clinician) - 2 IV / IM / SQ controlled medications with 1 of the following:
Ostqry(s), waluate/change q .eplacq (by dinician or nu6e) * 3 ancillaries, or
sudr as: SD€dal studyx 1 * Sp{ial study x 1
- Colostomy - 3 IV/ IM / sQ cortrolH or non@nt@lled mediGtions wath 1 of
, Cystostomy 3 of thefoililinsr the following:
d Gastrostomy - Brething tr€tment * 3 ancillaries, or
Il@stomy - Consuhation in ED or by phone * Spcial study x 1
' d1-3ancillaris
- Tradlsstomy
- History obtained from another source Modsate sedatim with 1 of the follfling:
. Overde wlthout wfrlep/msult/meds - Meds in ED - 3 ancillaries, or
- Pmription at D/C - Sp6ial study x I
. PICC lire q dlalysis eth. @mplaint/ prcblm - R@rd rwiew with summary (inc. old test(s)
(to be chec(ed or leaking etc...) - Temp > 100.5 F or 38 C, including history of Psych with @Nult and 2 of the follrying;
-Admission / Transfer
.l4RI=1 . P6qiption drug managmst Urlmry rctention with plaement of stEigltt or d Mediction(s)
. MRI head/MM head & fol€v atheter d Work-up
neck = 2 . Psych assEsmst without a psych s sial comult - Overdose (intstional)
X-Eysl - Restraints, chemi@l or physiGl
.MRA+MRI=1 Routine Dialysis with labs d2-3x-raypoints,or - Suicidal or homicidal patient
.I4RV+MRI=1 - Spine - multiple series x 2 or more
. Nuclear Medicine = 1 vaginal bledlng d disharge w/o abdominal paln spsial studi6:
. Pelvic US (transabdominal d 1 sEEcial study, with all ofthe following:
and/or transvaginal) = 1 x-rays, single set or wtth I of thefollwingl * 3 ancillaries, and
. &1, * IV fluids, and
Ihoracic/Lumbar - PO, eye, ear, toptal, OTC dEds (any number), intramsal, or
* IV, IM or SQ meds
CToTMRI=1 - Prescription on discharge, or
. TGUma 5@n = 2 - 1-2 lab6 - 2 special studie
.US=1
.VQscan = 1 TErsfusid of bl@d or blood products

Vagiral dellvery

X-Eys x 4 points

o11o112020
Desktop Coding Guide He,qrrx Canu Frx,qxcmr Snnucns
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Introduction
In an effort to more clearly and accurately determine the medical decision making (MDM) of charts for Medicare, all governmental
payers, and all private payers, it is our intent to follow CMS guidelines. The Desktop Coding Grid (MDM Physician Component)
and the Desktop Coding Guide have been created to act as adjuncts to assist coders in the use of the CMS guidelines. The following
directions are based upon those guidelines. The Desktop Coding guide provides guidance in the form of definitions and clarifications
to help in determining the level of Medical Decision Making from clinician documentation. This guide defines and explains various
points found on the Desktop Coding Grid in an attempt to obtain a higher degree of clarity and to explain each with a focus on the
practice of emergency medicine.

Fundamentally, CMS adheres to the MDM criteria for evaluation and management services found in the current CPT manual.
Additionally, CMS expands on those criterion in both the 1995 and, 1997 CMS Documentation Guidelines. The levels of EIM services
recognize four types of medical decision making (straight-forward, low complexity, moderate complexity and high complexity).
Medical decision making refers to the complexity of establishing a diagnosis andlor selecting a management option as measured by:

. Number of Diagnosis and Treatment Options

o Amount and/or Complexity of Data Reviewed
o The Risk of Complications and lor Risk of Morbidity and/or Mortality

Choice of any emergency medicine E/M code level is dependent upon proper documentation of the History, Exam, and MDM.
Clinician documentation must include the correct number of elements, items, or systems required for the HPI, ROS, PFSH, and Exam.
The documentation requirements for both the history and exam must meet or exceed the code level selected based on the MDM. If the
documentation of the history or the exam is insufficient to reach the code level that could be achieved by way of the MDM level, the
E/M level will be coded to the appropriate level based on the history or exam documentation. Example: A chart is assessed to be a
level 5 by way of the MDM. The history meets the requirements for the HPI, ROS, and PFSH, but the required amount of exam
elements for a level 5 is insufficient and reflects a level 4. The correct code allowed relative to the documentation would be a level 4.

This document is to be used solely as an adjunct to the Coding Policy and Procedures Manual with respect of the MDM component
only and is not meant to replace the general coding guidelines stated in the Coding Policy and Procedures Manual.
Desktop Coding Guide Hser"ru Caxr FrNaNcrar, Ssnvrcss
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Grid Application
To ensure that TeamHealth Coders correctly determine the level of Medical Decision Making (MDM) Component for Evaluation and
Management Services. TeamHealth coders utilize the Desktop Coding Grid (MDM Physician Component) for evaluation of the
MDM. The grid is developed from the CMS MDM criterion - Number of Diagnosis and Treatment Options; Amount and/or
Complexity of Data Reviewed; and the Risk of Complications and lor Risk of Morbidity and/or Mortality.

The Desktop Coding Grid has been created in a one-step format. Depending on the presentation or the reason for the visit, the final
diagnosis, course in the ED or testing performed; the Coder selects a preliminary level from the 5 columns listed.

In general, the presenting problem is usually the most important factor in dictating the level of service. However, in many cases a
seemingly benign complaint can alert the clinician to underlying risk factors and issues that require some in-depth investigations that
may indicate a more complex case.

Bxamples for MDM Level9928l are as follows:

o ED visit for a patient with a rechecVreturn visit of a medical condition that is stable or improving.
o ED visit for a patient for removal of sutures from a well healed, uncomplicated, simple laceration
Examples for MDM Level99282 are as follows:
. ED visit for otherwise healthy patient with sore throat (minimal exam of 2 BA/OS) advised to purchase OTC medication
o ED visit for a patient with minor trauma to extremify with localized pain (minimal exam of 3 BA/OS with neuro exam of
reflexes and sensation only) requiring no ancillary test, no meds in the ED, and no prescription.
r ED visit for a young adult with injected sclera and purulent discharge from both eyes without pain, visual disturbance, or
history of foreign body in either eye requiring visual acuity without slit lamp or stain.

Examples for MDM Level99283 are as follows:

o ED visit for patient complaining of acute pain associated with suspected foreign body in eye requiring eye exam with
fluorescein stain
. ED visit for a sexually active female complaining of vaginal discharge and denies experiencing abdominal pain.
Examples for MDM Level99284 are as follows:
o ED visit for a patient complaining of abdominal pain and rectal bleeding requiring a rectal exam
Desktop Coding Guide Hp-er,rx Cexs FniANcrAL Smxrrucns
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o ED visit for a patient complaining of chest pain requiring an EKG

r ED visit for a patient who has fallen, is now complaining of pain to her wrist, and receives an IM controlled medication x I
and x-ray of the wrist/hand
e ED visit for a child who fell off a bike, sustaining a head injury with brief loss of consciousness requiring a CT
o ED visit for a patient with an inversion ankle injury, who is unable to bear weight on the injured foot and ankle requiring an x-
ray of the ankle/foot, medication in the ED, and a prescription at discharge

Examples for MDM Level 99285 are as follows:

o ED visit for a patient with fracture of the hip with x-ray of the hip/pelvis and lumbosacral spine requiring admit to the OR
o ED visit for adult injured in automobile aceident brought to ED immobilized with symptoms compatible with internal injuries
requiring a chest tube
o EDvisit for patient with shortness of breath requiring continuous breathing treatment, CBC, ABG, CXR, IV medication
o ED visit for patient with sudden onset of a headache requiring 2 IM controlled medications and a CT
o ED visit for patient with suicidal ideation requiring consult, medication and transfer

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Desktop Coding Guide Hn*rrr Caxe FrNeNcrer $snvlcns
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Definitions & Clarifications:

Abdominal Pain
Some equivalent terms: cramping, discomfort, flank pain, flank tendemess, pelvic pain, pelvic tenderness, abdominal tendemess,
suprapubic pain, vaginal pain, and vaginal tenderness. Inguinal/groin pain can be considered as abdominal pain when the test relate to
the abdominal area (i.e. ab US, UA, etc.). Otherwise, the pain would be viewed as being related to the extremity area.

ABG. or CBG. or YBG

Credit for an arterial blood gas (ABG), or capillary blood gas (CBG), or venous blood gas (VBG) draw will begin at level4.

Ancillaries
Labs, EKGs and x-rays. Credit may be given for order, performance, completion, or interpretation. Each test is counted separately.
Credit is not to be given based on an order of "if indicated" alone for the particular test the "if indicated" is addressing. There must be
documentation to support the order as being carried out.
. Diagnostic test ordered or scheduled for a time after a patient leaves the ED can be considered.
o :
Labs - UA, urine culture(s) :2; CBC, PTPTT, amylase 3. Exception: CMP 2 labs. :
o Peak flow is not a lab
o BC or BCX are the most common abbreviations for blood culture(s).
o WC UDS (Workers Comp Urine Drug Screen) is not considered for the purposes of the grid
o BAL (Blood Alcohol Level) is not considered for the purposes of the grid when ordered from an outside source (i.e.
police)
o X-rays: Each x-ray is counted separately; exceptions are indicated in below table

AAS ( Acute Abdominal Series)

:1po int for one interpretation
=2po ints for two distinct intemretations Hio to ankle:2
Ankle/foot: I Hio/oelv s- bilateral: I
Ankleifoot/toe: I Hio/oelv s- unilateral: I
Babvsram = 2 (aka "nose to rectum" x-rav) Knee/oatella: I
Bilateral x-ravs (exceot hio/oelvis) : 2 Lumbar/sacral = 1
Bone survev: 2 Lumbar/sac r aU coccvx : 2
Chestlribs =- 2 Pre and Post x-rays: I
Desktop Coding Guide Hrerrs Cexn Frueucw Snmncns
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Comparison x-ravs : 1 Radius/ulna: 1

Complete sDine series = 3 Sacrum/coccvx: I
Face/nose: 1 Shoulder to wrist : 2
Foot/calcaneus: 1 Shunt Series: I
Foot/toe = I Tibula/fibula: I
Forearm and hand = 2 WrisVhand: I
Forearm./wrist: 1 Wrist/hand/finger: 1
Hand/finger = 1 Wrist/navicular: I

Blood Products
Must be given or started in the ED. Examples: packed cells, FFP, platelets, Factor VIII, albumin, whole blood

Breathing Treatments
Credit may be given for the order or administration.
o Medications in breathing treatments are part of the treatment and not considered for credit as other medication on the grid.
o Examples of meds used in breathing treatments include: albuterol, Atrovent (ipratropium), racemic epinephrine, salbuterol,
Xopenex (levalbuterol), Combivent (albuterol il ipratropium), DuoNeb (albuterol il ipratropium), Brovana (arformoterol).
. They may refer to this as a breathing treatment, breathing tx, nebulizer, neb tx, updraft nebulizer, updraft, continuous neb,
aerosol treatment, hand held nebulizer (HHN), etc.

Cardiac Enzvmes
Credit can be given for order, performance, completion, or interpretation. Cardiac enzymes receive credit for I lab, regardless of how
many are indicated in the record. Examples: Troponin, Creatine Phosphokinase Myoglobin (CPK-MB), and Myeloperoxidase (MPO).
Under certain circumstances, Creatine Phosphokinase (CPK often shortened to CK) and Myoglobin (MB) are used to determine non-
cardiac muscle mjury. Therefore, a Creatine Phosphokinase (CPK or CK) or Myoglobin (MB) alone does not receive credit as a
cardiac enzyme. They must be together or with another cardiac enzyme to receive credit for the purposes of the grid.

Cerebellar Findinqs
Problems with balance such as a Rhomberg test or ataxia. Symptoms that indicate cerebellar findings are positional vertigo from an
inner ear problem, slurred speech, nystagmus, and certain tremors.
Desktop Coding Guide Hner,rn CanB FrueNclnr Spnvlcps
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Chemical Cardioversion
99285 - "Critical care scenarios/management options (w/o CC time) such as: Chemical cardioversion"
Often documentation does not indicate "chemically converted" when a patient presents with a rapid heart rate that requires medication
to convert the heart to a normal rhythm; therefore, the focus will need to be on a combination of the diagnosis and the medications
used. There are many diagnoses and many beta blockers that can be used to chemically convert a patient; these are a few common
ones.
. Examples of diagnoses: SVT (supra ventricular tachycardia), rapid atrial fibrillation or rapid atrial flutter, PAT (Paroxysmal
Atrial Tachycardia)
. Examples of medications: Adenocard (adenosine), Cardizem (diltiazem), Lopressor (metoprolol), Toprol (metoprolol), Calan
(verapamil)

Chest Pain
Some equivalent terms: chest achiness, chest discomfort, chest pressure, chest soreness, chest tightness, pleuritic chest pain, and rib
pain.

Chief Comnlaint

C onsult/Discussion with Healthcare Clinician

A consultation is defined as communication/dialogue between TH clinician and any other health care clinician whose assessment
a
and plan/recommendations/discussion has an impact on the patient's plan of careldisposition. Examples of consultants: admitting
MD, private MD, SANE nurse, specialty MD, social services, poison control, toxicologist, Pharmacist, Dietician, Case Manager,
hospice nurse, etc.
r Documentation in the record of the consultant's note is acceptable for assigning credit for this bullet point
. A written consult usually contains an evaluation and plan/recommendations
. A patient evaluation alone is not a consult
o Documentation in the clinician's note may contain one of these acceptable statements from the TH clinician to assign credit
for this bullet point, as long as the name or specialty of the consultant is given (list not all inclusive):
Desktop Coding Guide HBALrH Cann FrN*Ncmr Srmrucns
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"consulted" "discussed with"

o'consulted
with" "discussion"
"consultation" "spoke with"
*"On consultation with Dr. Smith, it was his/her opinion..., *"I asked Dr. Smith to see the patient and he/she..."
"Mobile crisis was asked to see the patient and their note is "I contacted Dr. Smith and he/she saw the patient and
attached. .. " requested we discharge the patient to outoatient rehab."
*"Per Cardiology..." *"Cardiology recommended.
* - indicates elaboration needed
.. "

Communication between a TH clinician on duty with a TH clinician functioning as another healthcare clinician when not on
duty can be given a consult credit.
A read or report by a radiologist or simply a discussion of the test results does not receive a consult credit, however a
discussion of more than just test results would be given consult credit.
Unacceptable examples: Only an order for a consult. "Order name: Consult PMD: Dr. Smith,,, does not show the TH clinician
actually communicated/discussed with Dr. Smith. This can be viewed as an order for a consult, but not accepted as being
carried out' Nurses' note stating "mobile crisis contacted," or "spoke with poison control" neither example shows the
participation of the TH clinician.
-
Credit may be given for the nurse stating the TH clinician spoke with the consultant.

chA
Chest tube, Central line, Chemical cardio version, CPR throughout visit, BT Intubation, Gastric lavage for overdose or GI bleed,
Lumbar puncture, Thoracentesis, TPA. Credit is given for the performance, not simply the order, of th.r" scenarios/management
options by the TH clinician. If; for any reason, a patient refuses any of these r..nu.ior/*anagement options, no credit is to be given
and other points are to be considered.

Diagnosis
Cannot be extracted from the nursing notes; it must be docurnented by the TeamHealth clinician. The diagnosis cannot be extracted
solely from the ROS or examination.
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Fever
The degree/centigrade must be documented. May be stated by caregiver (history of) and documented by clinician or nurse. "Fever" is
not sufficient.
r > 100.5 F or 38C
. If the fever is given as a range (i.e. "patient's temperature ranges from 100o - l0lo"), can use the highest listed temperature.

Forensic Evidence Collection for Rape or Crime (bv Clinician)

A physical evaluation specifically performed by the clinician to collect rape, crime, suspected/suspicion of a rape or crime, or an
alleged rape or crime evidence such as pictures, body fluids, notation of bite marks or rope burns, etc.

Head Iniury with Neurolosical Chanse

Blunt head injury with a positive finding for any of the following: loss of consciousness, amnesia, weakness, numbness, paresthesias
(skin sensation such as burning, numbness, tingling, pin pricks, pins and needles), paralysis, confusion, dazed, dizzy, difficulty
concentrating, change in pupils (such as pinpoint, dilated), GCS (Glasgow Coma Scale) <15, nausea, vomiting, or a concussion. The
following are not considered neurological changes for head injury: headache. The diagnosis "post concussive syndrorne" generally
relates to a past head injury in which the patient complains of headaches/insomnia/mood changes, etc. [t is not generally used for a
current head injury. However, if the diagnosis is "post concussive syndrome" and the injury is within the past 7 days, it will be
sufficient for coding using this bullet point.

Historv Obtained from Another Source (ffifitS)

Credit may be given for the clinician's decision/need to obtain history regarding the patient from someone other than the patient. This
additional history could come from a parent, guardian, spouse, other family member, caregiver/sitter, EMS, nursing home staff, etc.

that additional history consisted ot. fii56fuoU -\W|,ED u.tl$e, Ef,tdlh,tWi

MW
In the case of pediatric patients, often the child is too young to articulate what is going on with them. In these situations parents or
other caregivers provide this information. For adult patients the need may arise to seek additional historical information from
someone other than the patient. This information is valuable to the clinician and has an impact on the care that is provided to the
patient.
Acceptable examples include:
o "Mother states child has had fever, vomiting, and not been eating well for two days."
Desktop Coding Guide Hrerxl Cera Fn*eNcrar Snnrflcss
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a "Additional history from patient's d,aughter" followed by details of that additional history information
a "History obtained from nursing hl6$,,,$ staff'followed by a recording of that information
a
il:rrii

anil:

lV Fluids
Credit may be given for the order or adrninistration. Orders that are canceled or placed on hold cannot receive credit unless there is
evidence the order has been reinstated or the IV fluid has been administered.
. Examples include: D5 %NS, D5 %NS, D5W, LR, NaCl, NS, normal saline, Ringer's Lactate, Lactated Ringer's
r lcc:1ml
. Examples of IV fluids: "fluid bolus", "IV fluid bolus", "IV bolus", "wide open"
. The fotlowing do not qualifr for IV fluid credit: TKO (to keep open), KVO (keep vein open), heplock, INT (insertion of IV
needle),IV flush, NS flush, "saline lock"
. For adult (14 years old and above) patients, if a drip rate is documented and that rate is 100 ml/hour or less it does not quali$
for credit.
. For adult (14 years old and above) patients, in general bags of IV fluids that are 250 ml or less are not considered IV fluids for
the purposes of the grid. These are not given for rehydration but rather as a vehicle to administer other intravenous
medications. Intravenous medications require dilution with fluids or damage can occur to the veins and surrounding tissue.
Two examples of commercially sold products are "Mini bag" and "Advantage bag." Any IV fluid given as bolus will be
considered as IV Fluids.

Medications
Credit mav be siven for the order or administration of P,,*,,,9.,"1,.19au-,,1*

edication orders that are canceled oi piu""A on

hold cannot receive credit unless there is evidence the order has been reinstated or the medication has been administered. For
"refused" medications refer to Refusal section of Guide. Multiple medications given in combination can be counted individually. For
Desktop Coding Guide Hpar,rn C*nB Fnq.aNcrer Srnucns
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example, an IM injection of Demerol and Phenergan is considered2 medications. Repeat medications are counted each time they are
given. For example, Phenergan IM at 2 am and Phenergan IM repeated at 5 am counts as 2 medications
. Banana bag or rally pack - credit counts as I IV medication and IV fluids
. GI Mix or GI Cocktail - credit counts as a single medication
. If l. p.tgcedure is performed but not billed, the medications used can be cou--qfg j1,.!.!g,l-{PM,,-qjid
r.l',,j$,6i'ffi:IVrcontrast is NOT counted as a medication. It is included inthe' hen ordered. The contrast
may be found ordered by name.in the medication section of a record byt !! l11o!to p-e.,gj
contrast media naflles in"lud"'
Ioxilan, Iopromide, lodixanol, Ioversol and Isovue.
o Medications without an administration route documented - default to the si
* catedindr'utloW*.
o Patient's own medications - if a patient is given their own routine medications while in the ED, it is not applicable for credit
on the MDM grid.
o Pedialyte is considered a PO medication
o PRN medications/orders are considered "prescription drug management" and should be counted in the MDM as fully executed
a
a

Split medications - Some IM or IV medications require the dose be split in to two or more injections/doses; this still only
counts as one medication. Example: the physician may order Rocephin 500 mg but it will require two injections to two
different sites (250 mg in each injection).
Tetanus IM injection - if patient receives both the Tetanus immunoglobulin and the Tetanus vaccine count as only 1 IM
injection
Topical medications -
o Transdermal patches/pastes are to be viewed as topical medications under level 3 on the MDM grid. This is applicable
to all patches/pastes. There is no distinction made between controlled and non-controlled.
o In the event of a billable procedure being performed and an application of a cream is applied to the area, it is then
considered part of the procedure and not applicable for credit on the MDM grid.
. Xylocaine (lidocaine) IM given with another medication: I IM medication. (e.g. Rocephin lgm wl 1%o Lidocaine IM)

t0
Desktop Coding Guide HEALTH Cexr FnraNcul SsRlrucrs
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. Xylocaine viscous (lidocaine); also known as "Magic mouthwash" or "Magic mouth rinse," swish by mouth - is considered a
PO medication

Monitored bed
Telemetry,ICU, CCU, PCU, MICU, SCU, PICU

Needle Stick/Bodv Fluid Exposure (ComplaintlProtocoUPanel)

A patient presents with complaint of being exposed to another person's body fluids and no symptoms reported. If symptoms are
reported, code to the appropriate level. Examples of body fluids include saliva/spit, blood, CSF, pus, mucus, urine, feces, and semen.
Methods of exposure include splashed inface/eye/mouthlbroken skin, punctured/stabbed skin with a used instrumenVneedle. This
complaint is coded as 99283 when some degree of work up or treatments is performed. The number of labs or medications does not
increase this service above that of 99283.

Neurological Exam
A neurological exam can be varied. It can be quite extensive or very brief. The neurological exam on paper templates and EMRs
differ across our contracts. Due to these reasons, any three distinctly different documented neurological elements, will be considered
as equivalent to "3 of the following" under level 3: 3 BA/OS with neuro exam as follows, 3 of the following.
. Acceptable examples include: cerebellar findings, coordination, DTRs, EOM intact, "neck supple", orientation, PERLA,
reflexes, sensation, "non-focal exam", documentation of Nexus Criteria. If these items are documented in an exam area other
than the neurological exam, they can be pulled and considered neuro.
o Attentiveness and eye contact as neurological elements are only for young pediatric patients, primarily just babies. This
allowance is for 2 years and less, unless there is some degree of mental deficiency involved. It is not to be used for older
pediatric patients or adults. Additional acceptable examples include "awareness", "interactive", "playful appropriate to age",
and "ambulates appropriate for age." If these items are documented in an exam area other than the neurological exam, they
can be pulled and considered neuro.
o The above two bullet points are the only items that can be pulled from other examination areas and used as neuro elements on
the Grid.
. General references to the neuro exam such as: "neuro normal," "neuro at baseline," and "neuro grossly intact" do not receive
credit as a full neuro or as I of "3 of the following" on the Grid.
. "Awake and alert": I neuro element only
. The presence of a neurological examination does not increase the level for a patient that is seen for suture removal

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Desktop Coding Guide Hrerru Cans FrueNcnr Srnucns
0U0t/2020 or ?EillfiHmlth

Ostomv
An operation that creates and opening from an area inside the body to the outside.

Overdose without Workup/Consult/lVleds

Credit may be given when an overdose (recreational, intentional or accidental) of a substance is suspected, or confirmed, and the
clinician does not order workup and/or medications and/or a consult. Examples include, but not limited to:
. An opiate overdose patient is given naloxone (Narcan) prior to arrival.
o A patient believes they have taken more than the prescribed dosage of their medication.
o A child suspected of ingesting a substance.

Palpitations
Definition of palpitation - abnormal heart beat that causes an awareness. Diagnoses consistent with palpitations (i.e. A fib,
Bradycardia, Tachycardia etc.) can be considered.

Pregnant Patient with Miscarriage/Snontaneous Abortion

The following terms/diagnoses are also included in this section: Complete Abortion, lncomplete Abortion, Septic Abortion, Missed
Abortion, Threatened AbortiorL Partial Abortion, Fetal Demise.

Prescription Drug Management

This item was formally known as "adjustment/review of current medications." Prescription drug management is appropriate when the
TH clinician documents the decision to start, stop, or continue medication(s). For example, patient is on Coumadin, recent blood work
was within an acceptable range and clinician indicates the patient is to continue on their current dose. Documentation of continued
medications alone does not increase the level of a patient being seen for recheck/return/suture removal.

Prescription on Discharse (Includes OTC Medication Instructions)

Acceptable documentation for Prescription on Discharge is listed below.
. Any medication written or "called to pharmacy"

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Desktop Coding Guide HeArrH Cenn FrNsr,icnr, Snmncps
olt0U2020 op'?ErillilHealth

o Medication documented in the prescription box (or its equivalent)

. Pre-packaged medications that cannot be re-used once opened when remainder is sent home with the patient (for example eye
drops, inhalers, Z-pack).
o Medications given to patient to take at home are acceptable even if only given enough for I day or less
. Any over the counter (OTC) medication is considered "prescription on discharge" if written as a prescription, called to
pharmacy, or documented in the prescription box (or its equivalent).
OTC medication exceptions are noted below and take precedence over the above bullet points. Example: physician template has the
"Rx given" box marked and the only prescription documented as being given was Tylenol; this is not sufficient for "prescription on
discharge." Reason - the OTC medication exceptions take precedence and Tylenol is never considered a prescription on discharge.
OTC medication exceptions:
o Benadryl (diphenhydramine), Tylenol (acetaminophen), and Aspirin (ASA, acetylsalicylic acid), regardless of dosing or
documentation, is not considered "prescription on discharge."
o Motrin/Advil (ibuprofen) is considered "prescription on discharge" only if the patient is directed to take 600-800 mg per dose.
Anything less than 600 mg per dose is not considered "prescription on discharge."
o AleveA',iaprosyn (naproxen) is considered a "prescription on discharge" only if the patient is directed to take 500 mg per dose
or more. Anything less than 500 mg per dose is not considered "prescription on discharge."
o Discharge notation such as "instructed to use OTC Neosporin," "use OTC Robitussin," etc. are not considered "prescription on
discharge."
Rx Refused: if a patient refuses to take a prescription that is given, it is considered as "Rx at discharge" and should be counted in the
MDM as fully executed.

Psvchiatric Diaenosis
Patient presents with a psych related problem and/or physician provides a final psych diagnosis. Psych may include alcohol abuse
sent for medical clearance. This is applicable to all psych points.

Rape with No Forensic Evidence Collection (bv Clinician)

A rape or alleged sexual assault without forensic evidence collected or a physical evaluation performed by a SANE nurse or other
ancillary personnel, someone other than the TH clinician, to collect evidence such as pictures, body fluids, notation of bite marks or
rope burns, etc. would start with this point.

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Desktop Coding Guide Hanr,ur Cenn FrNeNcrer Snnucns
oF TEAtrIHeaIth
011o112020

Recheck/Return Visits/Suture Removal

Return/recheck visits of a surgical procedure that are classified on the Grid as "complications/worsening" and do not require
medications, ancillary testing, prescriptions, etc. are considered 99281(if the payer is one that permits billing for complications). An
example of this is return visits for the repacking of an I&D with no other testing, meds, etc.

Record Review with Summarization

Old charts/records that have been reviewed and summarized by the clinician

ffP*rrdmission, transfer, or testing is counted as fully executed for medical decision making.
ffi An admission, transfer, or test(s) that is "deferred" is not the same as "refused" and not counted as a refusal.
Presence or absence of an order for the admission/transfer/test is not a determining factor.

Examples
o "Refused (admission, transfer, test)"
. "Refused treatment (medications, medications spit out by pediatric patients, fluids, etc.)"
. "discussed and refused (admission, transfer, test)"
. "declined (admission, transfer, test)"
r "offered and declined (admission, transfer, test)"
o Patient leaves AMA and tests, and/or medications , andlor admission are ordered, this is the same as "refused" and is counted
as fully executed for medical decision making.
o Refusal of a specific exam (pelvic, rectal, or slit lamp/fluorescein) is counted as fully executed for medical decision making.

o "deferred (admission, transfer, test)"

. "offered and deferred (admission, transfer, test)"

Repeat Exam by Clinician

A re-examination of an area a procedure was performed on does not qualiff for the repeat exam by clinician for the MDM grid. The
clinician is just checking the results of his/her procedure, just like they would when they are placing sutures. This would be
considered checking the status of a procedure they are performing.

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Desktop Coding Guide Hpnrxr Caxs FrxeNcrnr Snnvrcns
0110U2020 op TElffiilHcalth

Routine Dialvsis with Labs

A patient presents requiring routine dialysis. The patient receives dialysis and labs are ordered. Visits including the aforementioned
circumstance should be coded as99283. The following are part of normal routine dialysis and do not increase the level above 99283:
. Any number of labs
o Admitted/transferred to another area specifically and solely for routine dialysis (i.e. regular admit, monitored bed, telemetry,
ICU, etc.)
. Consultation to Nephrology or Hospitalist
o Complaint and/or treatment of nausea

However, if a patient presents for routine dialysis and any workup (beyond labs) or routine dialysis treatment (as defined above) is
ordered/performed, and/or the patient has an additional complaint (e.g. high fever, SOB, chest pain, etc.), code to the appropriate level.

Shortness of Breath
Examples that can be considered: wheezing and dyspnea. Coder can also consider "difficulty breathing" or "trouble breathing" if the
context of the visit is lung-related. For example, patient has difficulty breathing and has chest x-ray or VQ scan or d-dimer or receives
rescue inhaler. If the context of the visit is nose/throat related (e.g. difficulty breathing due to a stuffed up nose) these two terms
("difficulty breathing" and "trouble breathing") are not equivalent to shortness of breath.

Special Studies
Each test is counted separately. Credit can be given for order, performance, completion, or interpretation.
o CTs with and without contrast or with both oral and IV contrast receive credit for I CT
. Diagnostic test ordered or scheduled for a time after a patient leaves the ED can be considered
o A Bladder Scan is not considered a special study for the purposes of the grid. This is a nurse-performed, bedside procedure
that is used to assess the amount of urine, if any, in the patient's bladder
o Use of a Doppler for assessment of fetal heart tones (FHT) or peripheral pulses does not receive credit as a Doppler study

Arteriogram: I HIDA scan: 1

Arterial duplex US * venous duplex US : 1 IVP 0ntravenous Pvelosram): I

tsilateral CT scans : I MRA: I
Bilateral ultrasounds : I MRI :l
CT or CAT scan : I MRV: 1

CT+CTA:1 MRI headAvIRA head & neck:2

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Desktop Coding Guide HSALTH Carc FrNeNcn* Snnvlcps
01./0t/2020
op TtAiilHealth

CT Abdomen + Pelvis: 1 MRA + MRI: I

CT abdomen/pelvis + renal/stone study/protocol = 1 MRV+MRI:I
CT head/CT face: I Nuclear Medicine: I
CT headiCTA head & neck= 2 Pelvic US (transabdominal and/or transvaginal) : 1
CT head with maxilla (upper iaw) or any area above maxilla = I Thoracic/Lumbar CT or MRI: I
Trauma Scan (typically includes at least 3 CTs such as head,
CT head with mandible (lower jaw) or any area below mandible:2
abdomen. and chest: 2
Doppler studv: I US (ultrasound): I
EEG: I VO scan: I
FAST exam: I

Special Treatment Area

A patient sent to another department for an outpatient test or treatment. This refers to patients that are assigned to observation status
or patients that are sent to the GI lab, cardiac lab, interventional radiology, outpatient treatment area, detox unit, etc. for such test as an
Echo, EGD, stress test, etc. Examples of acceptable'documentation are "sent to Gtr lab for EGD", "transported to...", "taken to...", or
"patient moved to ...". At a minimum, it will be acceptable to take, for example, "to G[ lab" even without the specific procedure.
Such information may be taken from the nurses notes. If there is no such statement to show the patient was sent for a test or to one of
these departments, look to other points on the grid for appropriate MDM determination.

Suture Removal
A return visit for suture removal is considered9929l. The presence of a full neuro examination, andlor documentation of continued
medications, does not increase this service to a higher level. In addition, Bacitracin alone and similar topical antibiotic ointments (e.g.
Neosporin, Neomycin), do not raise the service above that of 99281. Additional treatments or medications, if present, can increase the
level as outlined in this Grid/Guide.

SyncopelNlear Svncope
Some equivalent terms: blackout, fainting, near fainting, (pre) syncope, vasovagal attack. A patient complaint of feeling as if they will
pass out is an acceptable description for near syncope.

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Desktop Coding Guide HsArlH C*nn Fnuemcml Snmrucns
0y0t/2020 or TEililHeahh

Test
Lab(s), x-ray(s), EKG(s), special study(ies), or any other test ordered. Credit can be given for order, perforrnance, completion, or
interpretation. Test orders that are canceled or placed on hold cannot receive credit unless there is evidence the order has been
reinstated, performed, completed, or interpreted.
. Diagnostic test ordered or scheduled for a time after a patient leaves the ED can be considered.
r Watch for multiple interpretation reports identifuing the same test, e.g., a preliminary report and a final report. This only
receives credit f,or the I test.
o Use of a cardiac monitor, pulse oximetry, and fetal heart tones (FHT) does not receive credit as a test for the purposes of the
grid.

Transfers
"A transfer is for continued care, for further evaluation or treatment" Examples: Transfer by EMS to another hospital offering
"specialty" services for eonditions that the current facility does not, or transfer to a psych facility by Police/Sheriff for additional
treatment of a patient. Patients transported back to their originating facility; ex: patient transferred/transported back to nursing home;
patients transferred/transported to jail do not receive credit for a transfer for the purposes of the grid. Please note; transfers of care
(shift change) between TH clinicians is not considered for the purposes of transfers on the grid.

Urinarv Retention with Placement of Straieht or Folev Cath

Urinary retention is the inability to empty the bladder, from urinating very small amounts of urine to the incapability to urinate at all.
Anyone can experience urinary retention, but it is most common in men in their fifties and sixties because of prostate enlargement.
Urinary retention can be caused by an obstruction in the urinary tract or by nerve problems that interfere with signals between the
brain and the bladder. A weak bladder muscle can also cause retention. Placement of a straight or foley cath in the ED is required to
empty the bladder. A urinary straight catheter is used only for short-term (intermittent) drainage. A foley catheter is used for both
short-term and long-term (indwelling) drainage.

Without workup
No more than one test

Workup
More than one test

L7
 LITBORATORY STUDIES

ELEltEt{TS/RfSUtTS
* Elements - what are included in the lab test or; Results
I.ABORATORYTEST ABBREVIATION # OFTEST COMMEI{TS
an example of an interpi for considefation on records
v'i*h^r,t l-h
^r;^r-

\CCU CHECK 1 :ount each one separatery lesult example - 99 mg/dl or 5.5 mmoyl
\LCOHOL LEVEL .TOH OT ALCOIIUL 1 Jne or more counts as one ooint {esult examole - 80 mo/dL or 0.080/o
II I(AI TNF PHOqPHATASF \lk Phos lev.r drdFre.l elnm Indrrdad in CMP
Jften seen wim abdominal parn. Not usuaily orderec
\MYLASE 1 ilone. Typically ordered with Lipase. Credit when
rapnwifhlinr<e = l lrh
\tsb Eremems - Pamar pressure 0l orygen (Pauz), Pafuar
)ressure of carbon dioxide (PaCO2), pH, Oxygen
\RTERIAL BLOOD GAS \BG 1 ..',r.fi^arc.nf\ ei.,#6+a - /!an2l
\BG Resuft example - PaOz 85 mmHg, PACO2 40 mmHg,
rH 7 4n qan? q7 H,.r)l 74 mFdll
Inese tesE are name dfferenf,y at some tacilr[es, f,errErru - Ldreruil (purr, u.w[ qoxEe (orcarrerErerr
)ut are the same: Chem, SMA or a SMAC 1-8 = lhloride, Creatinine, Glucose, Potassium. Sodium, Urea
]ASIC METABOUC PANEL 3MP 1
lMP. If CMP and BMP are ordered it is only a credit ,litrogen (BUN). GFR (glomerular filtration rate) Renal
rf , +^Bl h^ihk irh*i^h t6d-v

]ETA SUBUNIT lCG or Serum Pregnancy Test 1 (esult examples - negative or positive

legardless of how many blood cultures are ordered;

]LOOD CULTURE lC xl or BC X2 1 ti\,^ -r^Ai+ C^. 1 t^-t
{easures me amount ot me ENP hormone rn your
]RAIN NATRIURETIC PEPTIDE NP I ,ood, Not to be confused with BMP (basic metaboli(
)ution is advised when there is a reference to CBG.
}PILLARY BLOOD GAS :BG 1 This is also ttle abbreviation for Capillary Blood

]EREBRAL SPINAL FLUID ]SF I

-mamyola cufture.
lhlamydia swab,
]HLAMYDIA OR CHLAMYDIA DNA I See 'GC/Chlamydia"
lhlamydia probe,

Elerlrcnb - wr, K&, lq rrorPrpt9gy, ngu. ncq ryrLv,

I :BC or CBC with Diff 1 lab
*gs, Lymphs,
[4CH, MCHC, RDW, Platelet Diff type,
]OMPLETE BLOOD COUNT :BC = Yonos, Eos, Basos, Neut#. Lymph#, Mono#, Eos#,

Elements - Albumin. Bilirubin (total). Calcium (total),

l-hese tests are named differently at some facilities,Carbon dioxide (bicarbonate), Chloride. Creatinine.
rut are the same: Chem, SMA or a SMAC 9 and up = Glucose, Phosphatase alkatine, Potassium, ftotein (total),
]OMPLETE METABOUC PANEL :r,rP 2
:MP, Chemistry panel, ChemisEy screen, If CMP anc Sodium, Transferase, alanine amino (ALT) (SGPT),
IMP are ordered it is only a credit of 2 total points aspartate amino (AST) (SGOT), Urea nitrogen (BUN), GFR
(olomerular filtration rate)

]-REACNVE PROTEIN :RP I

I-ogether with Myoglobin (MB) it is considered a
]REATINE PHOSPHOKINASE ]PK CK 1 :ardiac enzyme. Ordered without the MB or any
:ardiac enzyme it is considered an individual ancillary
lardiac Enzyme; regardless of how many, count as L
]REATINE PHOSPHOKINASE MYOGLOBIN :PK. MB 1

)o notcount as a separate lab unless rt is the only

]REATININE 1 ab ordered. Some hospitals order this as part of the

).DIMER 1

01,01.2020
 LABORATORY STUDIES

ELEMENTS/RESUtTS
*
LABORATORY TEST ABBREVIATION # OFTEST COMMENTS Elements - what are included in the lab test or; Results
an example of an interp; for consideration on records
!r,ilh^,,+ l.h
^rr6?-
DIGOXIN / LANOXIN LEVEI.

DILANNN / PHENYTOIN LEVEI.

DNA PROBE 1 iee "GC/Chlamydia'

DRUG SCREENING:
\lso known as: Drug testing; Drug Screen; Poison :xdrIpEs rncruoe r nL (marr]uana,,, oPrales, Darorluates
)ssQ esting; Toxicology assays. Screening for presence :barbs), benzodiazepines (benzos), cocaine, heroin
ASPIRIN/ TYLENOU ETOH TEVELS/URINE 1
DRUG SCREEN
JDS )f legal and/ or illegal drugs, One or more drug {esult example - Aspirin: < 100 mcg/ML; Tylenol: 10-20
:rrpen</drrrn leval. r^,hk rc I n^iht r.o/ml : FTa)H: > RO mdl.ll f>O ORo/.\
:RU :R URINE DIP I
3C / CHLAMYDIA I )ne or both = 1 lab
:SBS oT ACCUCHECK
3LUCOSE I lount each one separately lesult example - 99 mg/dL or 5.5 mmofl
rL LUlIUre, UL SWaDr Or
SONORRHEA DNA I iee "GQChlamydia'

]UAIAC or HEMOCULT 1

TEMOGLOBIN & HEMATOCRTT 1&H 1

IEPAT]C rcT -FT 1

IEPATIIIS SCREENING/PANEL .IEP

A, HEP B, HEP C 1 legardless of the combination, only count as 1 lab
TUMAN CHORIONIC GONADOTROPIN
Dreffiand blood testl
1CG Qual and/or HCG Quant I ;ee "Pregnancy Test"
TI,MAN IMMUNODEFICIENCY VIRUS qIDS tesq AIDS screen; Hry
\NTRANY TFq
<egaroEss ot lnnuenza Ay'ts or swaD, only count as I
NFLUENZA SCREEN/SWAB ab, If ordered with RS/ and/or adenovirus, assign
rhh, i^|al hr it
^ha ^^i^i
:ErrEtrE OI me anarysts trcruge - LDL, Lutfure, Lrysals,
:ommonly known as Synovial fluid analysis,
IOINT FLUID ANALYSIS ;Ft 1 rnd a Gram stain; these are tested on the fluid, not to be
\bbreviation stands for Synovial Fluid. . r^,i* flhl^^in
^6F64 '^*i^^ ^f
-ACTATE/LACnC ACiD 1

otten seen wfth abdominal pain. Not usually ordered

-IPASE 1 alone. Typically ordered with Amylase. Credit when
cAAn with Amvlaca = 1 llh
rne elemerus or a tuer pronte are not counleo
;eparately when they are ordered during the same
IVER FUNCTION TESTS ,isit. Often included in a CMP. Credit can be given Elements - Alb, Bilit, Alk phos, SGPT, SGOT, Bilid, GGT,
-Fr 1
br a liver (hepatic) profile if ordered alone, Records ASf, ALT (See comments)
vith Liver (hepatic profile values only- considered as

YME TITER 1

,IAGNESIUM vlq 1 {o credit is given when there is also a BMP or CMP,

,10NO SPOT

r ugcurqr wrur LredurE r[ospltoKtrtdse tL 6

:onsidered a cardiac enzyme. Ordered without the

MYOGLOBIN 4B I
?K (CK) or any cardiac enzyme it is considered an
^in,ii' '-l -^-ill-^,

01.01.2020
 LABORATORY STUDIES

ELEMEI{TS/RESULTS
t Elements - what are included in the lab testor; Results
IABORATORYTEST ABBREVIATION # OFTEST COMMENTS an example of an interp; for consideration on records
.^,ilk^..1 t-k
^ri^v-
\l5O KnOWn aS LUtrUre Or me uremrar orscnarge;
:ulture can detect: C. trachomatis, Chlamydia, Gonorrhea
)ENILE CULTURE I :enital exudate culture; Culture - genital discharge o
{erpes simplex

)REGNANCY TEST (blood or urine) 1L(J quiil. HL(l quant/ uP r . ilood HCG and / or Urine HCG = 1 lab; one or both
)f thes tpstq = 1 lah
)ROTHROMBIN T]ME rrl PTT/ APTT or INR
.f ordered witfi influenza and/ or adenovirus. assign
i,ESPIMTORY SYNCMAL VIRUS 15V 1 r^t, ^^^ Mi^l +^i.l f^r .ll

IETIC COUNT or RETICULOCYTE COUNT

1OTOVIRUS

JED RATE :SR ;ame as erythrocyte or sedimentation rate

;PUTUM CULTURE

;TOOL C-DIFF

;TOOL CULTURE ;TOOL C&S

;TOOL OVA & PAMSITES iTool o&P

\lso known as a Gasbointestinal Profile; GI Panel; GI Profile and Stool NAAT
Jsed to identify: Adenovirus F 40/41; astrovirus; Campylobacter; Cbstridium difficile toxin A/B;
:ryptosporidium; Cyc,lospora cayetanensis; E coli 0157; Entamoeba histolytica; enteroaggregative E coli (EAEC);
;TOOL rcR (Polymerase Chain Readion) 1
)nteropathogenic E coli (EPAC); enterotoxigenic E coli (ETEC) tt/sq Giardia lamblia; norovirus GI/Gu;
,lesiomonas shigelloides; rotavirus A; Salmonella; Sapovirus; Shign-like toxin-producing E coli (STEC) sb(1/su2;
;hiclla/€nteroinvasire E coli (EIEC): Vibrio: Vibrio cholerae: Yersinia erterocolitica
f bottr a rapid strep screen and throat culture performed
;TREPTOCOCCAL CULTURE 1 \lso known as a throat culture
- t lMi6t in t^t l
tf both a rapid strep screen and throat culture pefonn€d
;TRETTOCOCCAL SCREEN IBSA 1 \lso known as a rapid sEep test t

TEGRETOL LEVEL 1

IHYROID PROFILE rSH I fSH + T4 = I lab = Thyroid profile = t hb

rOX SCREEN I
lardiac Enzyme; reqardless of how many, count as 1
IROPONIN iROP I
IYl'E d( LKU55 ano I YrE d( SLKEE|I
-&C
TYPE & SCREEN is also known as TYPE & RH and T&S, or GRH I )ne or both = 1 lab
rr aRA DH-WDF\
JRIC ACID 1

Elements - color, Appearance, Glucose, pH, Ketones,

JRINALYSIS JIA 1 /A and a U/A micro = 1 lab Protein, Bilirubin, Blood, Urobilinogen, Specific Gravity,
i[]-r+^ r ^,.L^^*^ ^-]^,--^
\ notation of "urine culture, if indicated- or -reflex t0
:ulture" does not receive credit unless further
JRINE CULTURE :+S,Ucx 1
locumentation indicates the culture was actualv

JRINE DIP 1 JA and urine dipstick during the same visit = 1 lab

JRINE GLUCOSE 1 Result example - ggmg/dl or 5.5 mmoyL

JRINE HCG JPT 1 ;ee "Pregnancy Test"

01.01.2020
 L/TBORATORY STUDIES

ELEMENTS/RESULTS
!.ABORATORYTEST ABBREVIATION # OFTEST * Elements - what are included in the lab test or; Results
COMMENTS
an example of an interp; for consideration on records

JRINE REDUCING SUBSTANCES I

qbo known as Female genibl tract culture; Culture -
r'AGINAL CULTURE/SWAB I rervix; Endocervical culture, If ordered with Wet .'uthrre can detect: C. trachomatis, Chlamydia, Gonorrhea,
rlounvwet Prep, assign only one point total for both, 'lerpes simplex, trichomonas

/ALPROIC ACID / DEPAKOTE LEVEL tAL 1

/ENOUS BLOOD GAS /BG I

/NAMIN B PANEL l, 85, and B12 I
tl ordered with Vaginal Cukure/Swab, assign only
A'ET MOUNT/WET PREP {l/TMI, or KOH I )ne mint iotal f6r lhth
TVOUND CULTURE ,vouND c&s {erourc ano AnaerooE cu[ures, wnemer one or oom
r.d^n = i Mint

l
i
I

',1 .l
1
 Meoeridine
" *,ti Methadone
ffi
Ativan Midazolam
Morohine
Bunrenorohine Nalbuphine ;W,Wi&
/:t:i$iwr.t t:a:
W
,!:lrai

Demerol w
Diazepam Nubain
Dilaudid
,WWM
Diorivan
'|M: M Phenobarbital
Dolophine Prooofol 'ilWW,#iM
Duramorph
Stadol 'Wi&Wfi
Fentanyl 9iMMw wrqweiswt
Geodon
Haldol Thorazine
hvdromorohone Valium
Ketalaf kimDl&t route is IM)
Ketamine M|M;WW, Versed
Lorazeoam
Luminol

01.01.20
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