1、Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMaking Medical Documentation Simple and PainlessBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsA familiar lament.“No matter how much I write in my history an
2、d 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!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsBrought to you by e-Medtools an
3、d MedicalTemplatesPhysician designed medical documentation toolsStandardized patient encounter forms usingAdobe PDF TechnologyvUse as a paper form ORvComplete form electronicallyBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsDocumentation promptersv HC
4、FA 1997 documentation guidelinesQuality remindersv Medicare PQRICheckboxesv Save timev Save energyFillable Text Boxesv Easy to usev Save timev Save energyTime saved is Money earned!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsStill has easy to use ch
5、eck boxes and fillable text boxes!Now with new featuresv ROS with separate“yes”and“no”buttons for ease of documenting“pertinent positive and negative”findingsv“Reset”button for each section of ROSv Built in reminders of documentation guidelines for sections of the history and physical examv Link but
6、ton for 1997 Guidelines for Evaluation&Management Services Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsDocumentation reminders of requirements for the relevant sectionLink to the 1997 Guidelines for Evaluation&Management ServicesSeparate“yes”and“no”
7、options for documenting pertinent positive and negative responsesReset buttons Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMost healthcare providers do more work than their documentation supports!And,as the saying goes,if it isnt documented,it didnt
8、 happen!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsFact33-52%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=$30 99214-99213=$
9、30 If you see 30 patients per day you may lose$300 or more 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!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical document
10、ation toolsDecreasing 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!Brought to you by e-Medtools and MedicalTemplatesPhysician desig
11、ned medical documentation toolsq Easy to useq Legibleq Fast and simple to complete q Saves dictation and transcription costsq Fast and simple to implement in any practiceq Standardizes documentationq Enhances risk management strategiesq Reduces the risk of down codingvWhen documentation is appropria
12、te for billing code Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsLegible,thorough,and standardized documentation is a proven strategy to reduce riskvThorough documentation becomes the standard of carevImproved,thorough documentation can support Audit
13、s 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 ModuleBrought to you by e-Medtools and MedicalT
14、emplatesPhysician designed medical documentation toolsBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation tools The Centers for Medicare and Medicaid Services(CMS)has published definitions and documentation guidelines for the key components of a medical encounte
15、r note,using CPT codes.Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsHistoryExamMedical Decision MakingCounselingCoordination of CareNature of Presenting ProblemTime1997 Guidelines for Evaluation&Management Services http:/www.cms.hhs.gov/MLNProducts/D
16、ownloads/MASTER1.pdfKey components in selecting the level of E/M servicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsHPIROSPFSHType of HistoryBriefN/AN/AP
17、roblem FocusedBriefProblem pertinentN/AExpanded Problem FocusedExtendedExtendedPertinentDetailedExtendedCompleteCompleteComprehensiveNew patient evaluations MUST have at least a Detailed HistoryBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsEVERY encou
18、nter MUST contain a Chief Complaint!v Preferentially stated in patients wordsElements of HPILocationQualitySeverityDurationTimingContextModifying factorsAssociated Signs and SymptomsBriefContains 1-3 elements listed ExtendedContains 4 elementsOR discusses 3 chronic or inactive conditionsBrought to y
19、ou by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsConstitutional SymptomsEyesEars,Nose,Mouth,ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary(Skin,Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/ImmunologicProblem Pertin
20、entDocuments responses to the system directly related to the presenting problemExtendedDocuments 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 to
21、tal)Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsPast Medical Historyv Illnesses,Operations,Injuries and TreatmentsFamily Medical Historyv Include heritable diseases and those that place the patient at increased riskSocial Historyv An age appropriate
22、 review of past and current activitiesPertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPIComplete All initial inpatient services require a Complete PFSHDocument at least 1 item from EACH of the 3 areasBrought to you by e-Medtools
23、 and MedicalTemplatesPhysician designed medical documentation toolsBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsCardiovascularEars,Nose,Mouth,ThroatEyesGenitourinary(Female)Genitourinary(Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologic
24、PsychiatricRespiratorySkinDetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related areaComprehensiveA general multi-system examA complete exam of an organ system and other related body areas or organ systemsMost levels require a minimum of a Detail
25、ed ExamBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsDetailed3 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
26、12 organ systemsComprehensive2 elements*in at least 9 organ systems or body areas*Refer to 1997 Guidelines for Evaluation&Management ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsDetailedvDocument 12 elements*(NOT Eye and Psychiatric exams)vEy
27、e and Psych exams document 9 elementsComprehensivevDocument ALL elements*Refer to 1997 Guidelines for Evaluation&Management ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsConstitutionalVital signsGeneral appearance of patientNutrition,Body habi
28、tus,Development,Deformities,GroomingEyesInspection of conjunctivae and lidsExam of pupils and irisesOphthalmoscopic exam of optic discsEars,Nose,Mouth and ThroatExternal inspection of ears and noseOtoscopic examAssessment of hearingInspection of nasal mucosa,septum,and turbinatesInspection of lips,t
29、eeth and gumsExam of oropharynxNeckExam of neckThyroidRespiratoryAssessment of effortPercussion of chestAuscultationPalpation of chestCardiovascularPalpation of heartAuscultationCarotid artery examAbdominal aorta examFemoral arteries examPedal pulses examExtremities for edema or varicosities Chest(B
30、reasts)InspectionPalpationGastrointestinalAbdominal examLiver and spleen examHernia presence or absenceAnus,perineum,rectum examStool for occult blood1997 Guidelines for Evaluation&Management ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsLymph
31、aticNeckAxillaGroinOtherMusculoskeletalGait and stationInspection,palpation digits and nailsExam of bones,joints,muscles AND 1 or more Inspection or palpation Range of motion and presence/absence of pain Stability Muscle strength and toneSkinInspectionPalpationNeurologicCranial nervesDeep tendon ref
32、lexesSensationPsychiatricJudgment and insightOrientation to person,time,placeMemory,recent and remoteMood and affectGenitourinary MaleScrotal contentsPenisDigital rectal exam of prostate glandFemaleExternal genitaliaUrethraBladder examCervixUterusAdnexa/parametria1997 Guidelines for Evaluation&Manag
33、ement ServicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsNumber of DiagnosesOr Management OptionsAmount and/or Complexity of Data to be ReviewedRisk of C
34、omplications and/or Morbidity or MortalityComplexity of Decision MakingMinimalMinimal or NoneMinimalLimitedLimitedLowMultipleModerateModerateExtensiveExtensiveHighBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsBrought to you by e-Medtools and MedicalTe
35、mplatesPhysician designed medical documentation toolsMust meet all criteria 99223Comprehensive History and ExamHigh complexity Medical decision making99222Comprehensive History and ExamModerate complexity Medical decision making99221Detailed OR Comprehensive History and ExamStraightforward or Low Co
36、mplexity Medical decision making Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMust meet all criteria99255 Comprehensive History AND Exam High complexity medical decision making99254 Comprehensive History AND Exam Moderate complexity medical decision
37、making99253 Detailed History AND Exam Low complexity medical decision makingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMust meet all criteria99205v Comprehensive History and Examv High complexity medical decision making99204v Comprehensive History
38、and Examv Moderate complexity medical decision making99203v Detailed History and Examv Low complexity medical decision makingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMust meet all criteria99245v Comprehensive Historyv Comprehensive Examv High com
39、plexity medical decision making99244v Comprehensive Historyv Comprehensive Examv Moderate complexity medical decision making99243v Detailed Historyv Detailed Examv Low complexity medical decision makingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMus
40、t meet 2 out of 3 criteria99215 v Comprehensive Historyv Comprehensive Examv High complexity medical decision making99214v Detailed Historyv Detailed Examv Moderate complexity medical decision making99213v Expanded Problem Focused Historyv Expanded Problem Focused Examv Low complexity medical decisi
41、on makingBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsWe 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-
