<p>E/M TEMPLATE: Level 3 Initial Hospitalization</p><p>Necessary to bill for a level 3 Initial Hospitalization: High complexity medical decision making PLUS A comprehensive history AND comprehensive examination </p><p>MEDICAL DECISION MAKING (MDM) RULES High MDM when 2 of the following (from 3 categories) achieve 4 points each: 1. Extensive Number of diagnoses or management options Two problems inadequately controlled (2 points each) New problem requiring further work-up (4 points) 2. Extensive Complexity of data reviewed Review imaging study films (2), or obtain additional history from someone other than patient (2), or review lab reports (1)*, or order labs (1)*, or order diagnostic testing (1)* *If lab/tests are ordered and results are obtained during the same visit, 1 point total is given 3. High Risk of morbidity and mortality (4 points for any of the situations below) Chronic illness with severe exacerbation, progression, or adverse effect from treatment An abrupt change in neurologic status (seizure, TIA, stroke, weakness, sensory loss, AMS changes, marked worsening of degenerative disease) Drug therapy requiring intensive monitoring for toxicity (4 points), e.g., coumadin, immunosuppressants, some AEDs, black box drugs Illnesses that pose a threat to life or body function Prescription of parenterally controlled substances Decision to DNR Cerebral Angiography Examples: A patient with 1 new symptom/or complaint needing additional workup (with labs, imaging and EMG, EEG, spirometry, NBT/NPT) A patient with 2 inadequately controlled problems (weakness, sensory change, bladder, bowel, or non- neurologic disorder) A patient with a sudden abrupt change in neurologic status (TIA weakness) or known epileptic with breakthrough seizures and LOC. Or patient with late effect of stroke with speech/cognitive/motor problems Falls in Parkinsonian patients; MS patient with inadequately controlled complications </p><p>If counseling and/or coordination of care consumes > 50 % of the encounter with the patient and/or family, then bill for a level 3 initial hospitalization if the bedside and or unit/floor time is more than 35 minutes of an 70 minute evaluation. The neurologist must document the actual bedside and unit/floor time and a summary of the topics discussed. This can be used in place of the bulleted HX-PX-MDM system.</p><p>Comprehensive History </p><p>History of Present Illness Chief complaint, plus 4 or more points regarding location, quality, severity, duration, timing, context, modifying factors, and associated sign and symptoms Review of Systems Complete (10 or more systems) Past, Family, Social History Complete, 1 point each for past, family, social history</p><p>---AND---</p><p>© American Academy of Neurology Professional Association 05/2008 General appearance (1)</p><p>Single System Neurologic Examination (23 of 25 points)</p><p>Tone (1) 3 or more vital signs (1) Strength (1) Fundus (1) Reflexes (1) Cardiovascular Examination – pulses (1), bruits (1), or Coordination (1) auscultation of heart (1) (1 point maximum) Mental Status (5) Sensation (1) Cranial Nerves (8) Gait (1)</p><p>© American Academy of Neurology Professional Association 05/2008</p>