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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 requirements for the highest levels of medical billing.
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Physician designed medical documentation tools
MedicalMedicalTemplatesTemplates
Making Medical Documentation Simple and Painless
Brought to you by e-Medtools and MedicalTemplates
Physician designed medical documentation tools
ProblemProblemA 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!
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MedicalTemplatesMedicalTemplatesCan Help!Can Help!
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What are MedicalTemplates?What are MedicalTemplates?
Standardized patient encounter forms using
Adobe PDF TechnologyUse as a paper form
ORComplete form electronically
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MedicalTemplates FeaturesMedicalTemplates 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!
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The New Ambulatory Evaluation The New Ambulatory Evaluation Template from MedicalTemplatesTemplate 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
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Documentation reminders of requirements for the relevant sectionDocumentation reminders of requirements for the relevant section
Link to the 1997 Guidelines for Evaluation & Management ServicesLink to the 1997 Guidelines for Evaluation & Management Services
Separate “yes” and “no” options for documenting pertinent positive and negative responses
Reset buttons
Separate “yes” and “no” options for documenting pertinent positive and negative responses
Reset buttons
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Many Physicians Under Code!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!
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How Much Is At Stake?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!!!
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What Is The Gain?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!
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Benefits of MedicalTemplatesBenefits 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
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Professional, Medical and Legal BenefitsProfessional, Medical and Legal Benefits
Legible, thorough, and standardized documentation is a proven strategy to reduce riskThorough documentation becomes the standard of careImproved, 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
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A Quick Review of A Quick Review of Medical DocumentationMedical Documentation
RequirementsRequirements
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Patient EncountersPatient 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.
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Key Components of DocumentationKey Components of Documentation
History
Exam
Medical Decision Making
Counseling
Coordination of Care
Nature of Presenting Problem
Time1997 Guidelines for Evaluation & Management Services
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
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
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The HistoryThe History
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History Components and Levels History Components and Levels
HPI ROS PFSH Type of History
Brief N/A N/A Problem Focused
Brief Problem pertinent
N/A Expanded Problem Focused
Extended Extended Pertinent Detailed
Extended Complete Complete Comprehensive
New patient evaluations MUST have at least a Detailed History
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History of Present IllnessHistory of Present IllnessEVERY encounter MUST contain a Chief Complaint!
Preferentially stated in patients’ words
Elements of HPILocation
QualitySeverityDurationTimingContextModifying factorsAssociated Signs and Symptoms
BriefContains 1-3 elements listed
ExtendedContains 4 elements
OR discusses 3 chronic or inactive conditions
BriefContains 1-3 elements listed
ExtendedContains 4 elements
OR discusses 3 chronic or inactive conditions
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Review of SystemsReview of SystemsConstitutional SymptomsEyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary (Skin, Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/Immunologic
Problem PertinentDocuments responses to the system directly related to the presenting problem
ExtendedDocuments positive and negative responses to 2-9 systems related to the problem
CompleteDocuments all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total)
Problem PertinentDocuments responses to the system directly related to the presenting problem
ExtendedDocuments positive and negative responses to 2-9 systems related to the problem
CompleteDocuments all positive and negative responses to systems related to the presenting problem AND all other systems (10 or more total)
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Past, Family and Social HistoryPast, 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
PertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPI
PertinentDocument at least 1 item from ANY of the 3 areasIt must be directly related to the problems identified in the HPI
Complete All initial inpatient services require a Complete PFSHDocument at least 1 item from EACH of the 3 areas
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The ExamThe Exam
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Recognized Single Organ SystemsRecognized Single Organ SystemsCardiovascularEars, Nose, Mouth, ThroatEyesGenitourinary (Female)Genitourinary (Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkin
DetailedAn extended exam of the affected body area or organs/organ system and another symptomatic or related area
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 minimum of a Detailed ExamMost levels require a minimum of a Detailed Exam
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Multi-organ System ExamMulti-organ System ExamDetailed
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 examinedOR 1 element of at least 12 organ systems
Comprehensive2 elements* in at least 9 organ systems or body areas
*Refer to 1997 Guidelines for Evaluation & Management Services*Refer to 1997 Guidelines for Evaluation & Management Services
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Single Organ System ExamSingle 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*Refer to 1997 Guidelines for Evaluation & Management Services
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Elements of Individual Organ SystemsElements of Individual Organ SystemsConstitutional
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 Services1997 Guidelines for Evaluation & Management Services
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Exam elements, continuedExam elements, continuedLymphatic
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 Services1997 Guidelines for Evaluation & Management Services
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Medical Decision MakingMedical Decision Making
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Complexity of Medical Decision MakingComplexity of Medical Decision Making
Number of Diagnoses
Or Management Options
Amount and/or Complexity of Data to be Reviewed
Risk of Complications and/or Morbidity or Mortality
Complexity of Decision Making
Minimal Minimal or None Minimal StraightforwardStraightforward
Limited Limited Low LowLow
Multiple Moderate Moderate ModerateModerate
Extensive Extensive High HighHigh
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Examples ofExamples ofDocumentation Documentation Requirements Requirements
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Initial Hospital CareInitial Hospital CareMust 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
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Initial Inpatient ConsultationInitial Inpatient ConsultationMust 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
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New Outpatient EncounterNew Outpatient EncounterNot a ConsultNot 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
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New Outpatient ConsultNew Outpatient ConsultMust 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
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Established Outpatient EncounterEstablished Outpatient EncounterMust 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
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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
