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1、MedicalTemplates,Making Medical Documentation Simple and Painless,Problem,A familiar lament.“No matter how much I write in my history and physical exam note,I never seem to document enough to substantiate a high level encounter!”Medical documentation is not about HOW MUCH you write!It is about WHAT
2、you write!,MedicalTemplatesCan Help!,What are MedicalTemplates?,Standardized patient encounter forms usingAdobe PDF TechnologyUse as a paper form ORComplete form electronically,MedicalTemplates Features,Documentation promptersHCFA 1997 documentation guidelinesQuality remindersMedicare PQRICheckboxes
3、Save timeSave energyFillable Text BoxesEasy to useSave timeSave energyTime saved is Money earned!,The New Ambulatory Evaluation Template from MedicalTemplates,Still has easy to use check boxes and fillable text boxes!Now with new featuresROS with separate“yes”and“no”buttons for ease of documenting“p
4、ertinent positive and negative”findings“Reset”button for each section of ROSBuilt in reminders of documentation guidelines for sections of the history and physical examLink button for 1997 Guidelines for Evaluation&Management Services,Documentation reminders of requirements for the relevant section,
5、Link to the 1997 Guidelines for Evaluation&Management Services,Separate“yes”and“no”options for documenting pertinent positive and negative responsesReset buttons,Many Physicians Under Code!,Most healthcare providers do more work than their documentation supports!And,as the saying goes,if it isnt doc
6、umented,it didnt happen!,How Much Is At Stake?,Fact33-52%of patient encounters are UNDER coded(JABFP 2001;14:184-92 and FPM October 2003“How to get all the 99214s you deserve”)Differences in Medicare reimbursement 99214-99215=$30 99214-99213=$30 If you see 30 patients per day you may lose$300 or mor
7、e per day!33%(30 patients/day)x$30/patient=$300/dayWorking 5 days/week for 50 weeks,that is a potential loss of$75,000 in just 1 year due to inadequate coding!,What Is The Gain?,Decreasing billing and coding errors by just 50%could mean an increase of nearly$40,000 per year in practice revenues!The
8、equivalent of seeing an additional 690 patients/yearOr,an extra 3 patients/day!WITHOUT THE EXTRA WORK!,Benefits of MedicalTemplates,Easy to useLegibleFast and simple to complete Saves dictation and transcription costsFast and simple to implement in any practiceStandardizes documentationEnhances risk
9、 management strategiesReduces the risk of down codingWhen documentation is appropriate for billing code,Professional,Medical and Legal Benefits,Legible,thorough,and standardized documentation is a proven strategy to reduce riskThorough documentation becomes the standard of careImproved,thorough docu
10、mentation can supportAudits of Billing codeswhen correct code is billed for level of documentationMandatory Quality reportingPay For PerformanceQuality Assurance projectsMaintenance of Certification projectsSelf evaluation of practice performance ABIM Practice Improvement Module,A Quick Review of Me
11、dical DocumentationRequirements,Patient Encounters,The Centers for Medicare and Medicaid Services(CMS)has published definitions and documentation guidelines for the key components of a medical encounter note,using CPT codes.,Key Components of Documentation,HistoryExamMedical Decision MakingCounselin
12、gCoordination of CareNature of Presenting ProblemTime,1997 Guidelines for Evaluation&Management Services,Key components in selecting the level of E/M services,The History,History Components and Levels,New patient evaluations MUST have at least a Detailed History,History of Present Illness,EVERY enco
13、unter MUST contain a Chief Complaint!Preferentially stated in patients wordsElements of HPILocationQualitySeverityDurationTimingContextModifying factorsAssociated Signs and Symptoms,BriefContains 1-3 elements listed ExtendedContains 4 elementsOR discusses 3 chronic or inactive conditions,Review of S
14、ystems,Constitutional SymptomsEyesEars,Nose,Mouth,ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary(Skin,Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/Immunologic,Problem PertinentDocuments responses to the system directly related to the presenting pro
15、blemExtendedDocuments positive and negative responses to 2-9 systems related to the problemCompleteDocuments all positive and negative responses to systems related to the presenting problem AND all other systems(10 or more total),Past,Family and Social History,Past Medical HistoryIllnesses,Operation
16、s,Injuries and TreatmentsFamily Medical HistoryInclude heritable diseases and those that place the patient at increased riskSocial HistoryAn age appropriate review of past and current activities,PertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems iden
17、tified in the HPI,Complete All initial inpatient services require a Complete PFSHDocument at least 1 item from EACH of the 3 areas,The Exam,Recognized Single Organ Systems,CardiovascularEars,Nose,Mouth,ThroatEyesGenitourinary(Female)Genitourinary(Male)Hematologic/Lymphatic/ImmunologicMusculoskeletal
18、NeurologicPsychiatricRespiratorySkin,DetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related area,ComprehensiveA general multi-system examA complete exam of an organ system and other related body areas or organ systems,Most levels require a minimu
19、m of a Detailed Exam,Multi-organ System Exam,Detailed3 vital signsBP,sitting or standingBP,supinePulse,rate and regularityRespirationsTemperatureHeightWeight2 elements*of at least 6 organ systems or body areas examinedOR 1 element of at least 12 organ systemsComprehensive2 elements*in at least 9 org
20、an systems or body areas,*Refer to 1997 Guidelines for Evaluation&Management Services,Single Organ System Exam,DetailedDocument 12 elements*(NOT Eye and Psychiatric exams)Eye and Psych exams document 9 elementsComprehensiveDocument ALL elements*,*Refer to 1997 Guidelines for Evaluation&Management Se
21、rvices,Elements of Individual Organ Systems,ConstitutionalVital signsGeneral appearance of patientNutrition,Body habitus,Development,Deformities,GroomingEyesInspection of conjunctivae and lidsExam of pupils and irisesOphthalmoscopic exam of optic discsEars,Nose,Mouth and ThroatExternal inspection of
22、 ears and noseOtoscopic examAssessment of hearingInspection of nasal mucosa,septum,and turbinatesInspection of lips,teeth and gumsExam of oropharynxNeckExam of neckThyroidRespiratoryAssessment of effortPercussion of chestAuscultationPalpation of chest,CardiovascularPalpation of heartAuscultationCaro
23、tid artery examAbdominal aorta examFemoral arteries examPedal pulses examExtremities for edema or varicosities Chest(Breasts)InspectionPalpationGastrointestinalAbdominal examLiver and spleen examHernia presence or absenceAnus,perineum,rectum examStool for occult blood,1997 Guidelines for Evaluation&
24、Management Services,Exam elements,continued,LymphaticNeckAxillaGroinOtherMusculoskeletalGait and stationInspection,palpation digits and nailsExam of bones,joints,muscles AND 1 or moreInspection or palpationRange of motion and presence/absence of painStabilityMuscle strength and toneSkinInspectionPal
25、pationNeurologicCranial nervesDeep tendon reflexesSensation,PsychiatricJudgment and insightOrientation to person,time,placeMemory,recent and remoteMood and affectGenitourinary MaleScrotal contentsPenisDigital rectal exam of prostate glandFemaleExternal genitaliaUrethraBladder examCervixUterusAdnexa/
26、parametria,1997 Guidelines for Evaluation&Management Services,Medical Decision Making,Complexity of Medical Decision Making,Examples ofDocumentation Requirements,Initial Hospital Care,Must meet all criteria 99223Comprehensive History and ExamHigh complexity Medical decision making99222Comprehensive
27、History and ExamModerate complexity Medical decision making99221Detailed OR Comprehensive History and ExamStraightforward or Low Complexity Medical decision making,Initial Inpatient Consultation,Must meet all criteria99255Comprehensive History AND ExamHigh complexity medical decision making99254Comp
28、rehensive History AND ExamModerate complexity medical decision making99253Detailed History AND ExamLow complexity medical decision making,New Outpatient EncounterNot a Consult,Must meet all criteria99205Comprehensive History and ExamHigh complexity medical decision making99204Comprehensive History a
29、nd ExamModerate complexity medical decision making99203Detailed History and ExamLow complexity medical decision making,New Outpatient Consult,Must meet all criteria99245Comprehensive HistoryComprehensive ExamHigh complexity medical decision making99244Comprehensive HistoryComprehensive ExamModerate
30、complexity medical decision making99243Detailed HistoryDetailed ExamLow complexity medical decision making,Established Outpatient Encounter,Must meet 2 out of 3 criteria99215 Comprehensive HistoryComprehensive ExamHigh complexity medical decision making99214Detailed HistoryDetailed ExamModerate comp
31、lexity medical decision making99213Expanded Problem Focused HistoryExpanded Problem Focused ExamLow complexity medical decision making,We hope you found this presentation helpful!We are grateful to all the patient and knowledgeable billing and coding specialists we have encountered along the way!We welcome your comments at,
