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Medical Templates Making Medical Documentation Simple And Painless

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Making medical documentation simple and painless with template based documentation tools. Prompters help remind users about the 1997 E&M Documentation guidelines, to help insure compliance with the …

Making medical documentation simple and painless with template based documentation tools. Prompters help remind users about the 1997 E&M Documentation guidelines, to help insure compliance with the requirements for the highest levels of medical billing.

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  • 1. Medical Templates Making Medical Documentation Simple and Painless
  • 2. 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 you write!
  • 3. MedicalTemplates Can Help!
  • 4. What are MedicalTemplates?
    • Standardized patient encounter forms using
    • Adobe PDF Technology
      • Use as a paper form
      • OR
      • Complete form electronically
  • 5. MedicalTemplates Features
    • Documentation prompters
      • HCFA 1997 documentation guidelines
    • Quality reminders
      • Medicare PQRI
    • Checkboxes
      • Save time
      • Save energy
    • Fillable Text Boxes
      • Easy to use
      • Save time
      • Save energy
    • Time saved is Money earned!
  • 6. The New Ambulatory Evaluation Template from MedicalTemplates
    • Still has easy to use check boxes and fillable text boxes!
    • Now with new features
      • ROS with separate “yes” and “no” buttons for ease of documenting “pertinent positive and negative” findings
      • “ Reset” button for each section of ROS
      • Built in reminders of documentation guidelines for sections of the history and physical exam
      • Link button for 1997 Guidelines for Evaluation & Management Services
  • 7. Documentation reminders of requirements for the relevant section Link to the 1997 Guidelines for Evaluation & Management Services Separate “yes” and “no” options for documenting pertinent positive and negative responses Reset buttons
  • 8. Many Physicians Under Code!
    • Most healthcare providers do more work than their documentation supports!
      • And, as the saying goes,
      • if it isn’t documented, it didn’t happen!
  • 9. How Much Is At Stake?
    • Fact
    • 33-52% 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 more per day!
      • [33%(30 patients/day) x $30/patient = $300/day]
    • Working 5 days/week for 50 weeks,
    • that is a potential loss of $75,000
    • in just 1 year due to inadequate coding!!!
  • 10. 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 equivalent of seeing an additional 690 patients/year
        • Or, an extra 3 patients/day!
        • WITHOUT THE EXTRA WORK!
  • 11. Benefits of MedicalTemplates
    • Easy to use
    • Legible
    • Fast and simple to complete
    • Saves dictation and transcription costs
    • Fast and simple to implement in any practice
    • Standardizes documentation
    • Enhances risk management strategies
    • Reduces the risk of down coding
      • When documentation is appropriate for billing code
           
  • 12. Professional, Medical and Legal Benefits
    • Legible, thorough, and standardized documentation is a proven strategy to reduce risk
      • Thorough documentation becomes the standard of care
      • Improved, thorough documentation can support
        • Audits of Billing codes
          • when correct code is billed for level of documentation
        • Mandatory Quality reporting
        • Pay For Performance
        • Quality Assurance projects
        • Maintenance of Certification projects
          • Self evaluation of practice performance
          • ABIM Practice Improvement Module
  • 13. A Quick Review of Medical Documentation Requirements
  • 14. 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.
  • 15. Key Components of Documentation
    • History
    • Exam
    • Medical Decision Making
    • Counseling
    • Coordination of Care
    • Nature of Presenting Problem
    • Time
    1997 Guidelines for Evaluation & Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf Key components in selecting the level of E/M services
  • 16. The History
  • 17. History Components and Levels New patient evaluations MUST have at least a Detailed History Comprehensive Complete Complete Extended Detailed Pertinent Extended Extended Expanded Problem Focused N/A Problem pertinent Brief Problem Focused N/A N/A Brief Type of History PFSH ROS HPI
  • 18. History of Present Illness
    • EVERY encounter MUST contain a Chief Complaint!
      • Preferentially stated in patients’ words
    • Elements of HPI
    • Location
    • Quality
    • Severity
    • Duration
    • Timing
    • Context
    • Modifying factors
    • Associated Signs and Symptoms
    • Brief
    • Contains 1-3 elements listed
    • Extended
    • Contains  4 elements
      • OR discusses 3 chronic or inactive conditions
  • 19. Review of Systems
    • Constitutional Symptoms
    • Eyes
    • Ears, Nose, Mouth, Throat
    • Cardiovascular
    • Respiratory
    • Gastrointestinal
    • Musculoskeletal
    • Integumentary (Skin, Breast)
    • Neurological
    • Psychiatric
    • Endocrine
    • Hematologic/Lymphatic
    • Allergy/Immunologic
    Problem Pertinent Documents responses to the system directly related to the presenting problem Extended Documents positive and negative responses to 2-9 systems related to the problem Complete Documents all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total)
  • 20. Past, Family and Social History
    • Past Medical History
      • Illnesses, Operations, Injuries and Treatments
    • Family Medical History
      • Include heritable diseases and those that place the patient at increased risk
    • Social History
      • An age appropriate review of past and current activities
    Pertinent Document at least 1 item from ANY of the 3 areas It must be directly related to the problems identified in the HPI Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas
  • 21. The Exam
  • 22. Recognized Single Organ Systems
    • Cardiovascular
    • Ears, Nose, Mouth, Throat
    • Eyes
    • Genitourinary (Female)
    • Genitourinary (Male)
    • Hematologic/Lymphatic/Immunologic
    • Musculoskeletal
    • Neurologic
    • Psychiatric
    • Respiratory
    • Skin
    Detailed An extended exam of the affected body area or organs/organ system and another symptomatic or related area
    • Comprehensive
      • A general multi-system exam
      • A complete exam of an organ system and
      • other related body areas or organ systems
    Most levels require a minimum of a Detailed Exam
  • 23. Multi-organ System Exam
    • Detailed
      •  3 vital signs
        • BP, sitting or standing
        • BP, supine
        • Pulse, rate and regularity
        • Respirations
        • Temperature
        • Height
        • Weight
      •  2 elements* of at least 6 organ systems or body areas examined
      • OR  1 element of at least 12 organ systems
    • Comprehensive
      •  2 elements* in at least 9 organ systems or body areas
    *Refer to 1997 Guidelines for Evaluation & Management Services
  • 24. Single Organ System Exam
    • Detailed
      • Document  12 elements* (NOT Eye and Psychiatric exams)
      • Eye and Psych exams document  9 elements
    • Comprehensive
      • Document ALL elements*
    *Refer to 1997 Guidelines for Evaluation & Management Services
  • 25. Elements of Individual Organ Systems
    • Constitutional
      • Vital signs
      • General appearance of patient
        • Nutrition, Body habitus, Development, Deformities, Grooming
    • Eyes
      • Inspection of conjunctivae and lids
      • Exam of pupils and irises
      • Ophthalmoscopic exam of optic discs
    • Ears, Nose, Mouth and Throat
      • External inspection of ears and nose
      • Otoscopic exam
      • Assessment of hearing
      • Inspection of nasal mucosa, septum, and turbinates
      • Inspection of lips, teeth and gums
      • Exam of oropharynx
    • Neck
      • Exam of neck
      • Thyroid
    • Respiratory
      • Assessment of effort
      • Percussion of chest
      • Auscultation
      • Palpation of chest
    • Cardiovascular
      • Palpation of heart
      • Auscultation
      • Carotid artery exam
      • Abdominal aorta exam
      • Femoral arteries exam
      • Pedal pulses exam
      • Extremities for edema or varicosities
    • Chest (Breasts)
      • Inspection
      • Palpation
    • Gastrointestinal
      • Abdominal exam
      • Liver and spleen exam
      • Hernia presence or absence
      • Anus, perineum, rectum exam
      • Stool for occult blood
    1997 Guidelines for Evaluation & Management Services
  • 26. Exam elements, continued
    • Lymphatic
      • Neck
      • Axilla
      • Groin
      • Other
    • Musculoskeletal
      • Gait and station
      • Inspection, palpation digits and nails
      • Exam of bones, joints, muscles AND 1 or more
        • Inspection or palpation
        • Range of motion and presence/absence of pain
        • Stability
        • Muscle strength and tone
    • Skin
      • Inspection
      • Palpation
    • Neurologic
      • Cranial nerves
      • Deep tendon reflexes
      • Sensation
    • Psychiatric
      • Judgment and insight
      • Orientation to person, time, place
      • Memory, recent and remote
      • Mood and affect
    • Genitourinary
      • Male
      • Scrotal contents
      • Penis
      • Digital rectal exam of prostate gland
      • Female
      • External genitalia
      • Urethra
      • Bladder exam
      • Cervix
      • Uterus
      • Adnexa/parametria
    1997 Guidelines for Evaluation & Management Services
  • 27. Medical Decision Making
  • 28. Complexity of Medical Decision Making High High Extensive Extensive Moderate Moderate Moderate Multiple Low Low Limited Limited Straightforward Minimal Minimal or None Minimal Complexity of Decision Making Risk of Complications and/or Morbidity or Mortality Amount and/or Complexity of Data to be Reviewed Number of Diagnoses Or Management Options
  • 29. Examples of Documentation Requirements
  • 30. Initial Hospital Care
    • Must meet all criteria
    • 99223
        • Comprehensive History and Exam
        • High complexity Medical decision making
    • 99222
        • Comprehensive History and Exam
        • Moderate complexity Medical decision making
    • 99221
        • Detailed OR Comprehensive History and Exam
        • Straightforward or Low Complexity Medical decision making
  • 31. Initial Inpatient Consultation
    • Must meet all criteria
    • 99255
        • Comprehensive History AND Exam
        • High complexity medical decision making
    • 99254
        • Comprehensive History AND Exam
        • Moderate complexity medical decision making
    • 99253
        • Detailed History AND Exam
        • Low complexity medical decision making
  • 32. New Outpatient Encounter Not a Consult
    • Must meet all criteria
    • 99205
      • Comprehensive History and Exam
      • High complexity medical decision making
    • 99204
      • Comprehensive History and Exam
      • Moderate complexity medical decision making
    • 99203
      • Detailed History and Exam
      • Low complexity medical decision making
  • 33. New Outpatient Consult
    • Must meet all criteria
    • 99245
      • Comprehensive History
      • Comprehensive Exam
      • High complexity medical decision making
    • 99244
      • Comprehensive History
      • Comprehensive Exam
      • Moderate complexity medical decision making
    • 99243
      • Detailed History
      • Detailed Exam
      • Low complexity medical decision making
  • 34. Established Outpatient Encounter
    • Must meet 2 out of 3 criteria
    • 99215
      • Comprehensive History
      • Comprehensive Exam
      • High complexity medical decision making
    • 99214
      • Detailed History
      • Detailed Exam
      • Moderate complexity medical decision making
    • 99213
      • Expanded Problem Focused History
      • Expanded Problem Focused Exam
      • Low complexity medical decision making
  • 35.
    • 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
    • www.e-medtools.com