Health care management process done after performing a history and physical examination on a patient that results in a plan of treatment. It is based on establishing one or more diagnoses and/or selecting a management or treatment option, amount of data or complexity of data reviewed, and complications and/or morbidity or mortality. Four types of MDM are straightforward, low complexity (LC), moderate complexity (MC), and high complexity (HC).

Defined by Medicare, an anesthesiologist’s involvement with a certified registered nurse anesthetist (CRNA) or anesthesiology assistant (AA) in one, two, three, or four concurrent procedures where the anesthesiologist is physically present and where all the seven requirements are met and documented. Medicare does not recognize medical direction by the anesthesiologist if he or she is involved in more than four concurrent procedures. When the anesthesiologist takes on five or more cases, he or she is supervising or has failed to meet the medical direction requirements, with a few exceptions [Medicare Carriers Manual, Section 4830].

Usually a physician who is employed by a hospital or managed care organization (MCO) in an administrative capacity as head of the organized medical staff. He or she acts as a liaison for the staff with the administration and governing body.

Individual who reviews onscreen notes or a computer-generated hard copy document while listening to the physician’s voice on tape. The correctionist makes changes related to voice recognition errors such as corrections, changes, additions, and deletions. The final product is given to the physician for review before becoming part of the patient’s medical record. Also referred to as a correctionist . See also medical proofreader .