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Medical
TemplatesMakingMedicalDocumentationSimpleandPainlessMedical
TemplatesProblemAfamiliarlament...
“NomatterhowmuchIwriteinmyhistoryandphysicalexamnote,Ineverseemtodocumentenoughtosubstantiateahighlevelencounter!”MedicaldocumentationisnotaboutHOWMUCHyouwrite!ItisaboutWHATyouwrite!ProblemAfamiliarlament...MedicalTemplates
CanHelp!MedicalTemplates
CanHelp!WhatareMedicalTemplates?StandardizedpatientencounterformsusingAdobePDFTechnologyUseasapaperformORCompleteformelectronicallyWhatareMedicalTemplates?StanMedicalTemplatesFeaturesDocumentationpromptersHCFA1997documentationguidelinesQualityremindersMedicarePQRICheckboxesSavetimeSaveenergyFillableTextBoxesEasytouseSavetimeSaveenergyTimesavedisMoneyearned!MedicalTemplatesFeaturesDocumTheNewAmbulatoryEvaluationTemplatefromMedicalTemplatesStillhaseasytousecheckboxesandfillabletextboxes!NowwithnewfeaturesROSwithseparate“yes”and“no”buttonsforeaseofdocumenting“pertinentpositiveandnegative”findings“Reset”buttonforeachsectionofROSBuiltinremindersofdocumentationguidelinesforsectionsofthehistoryandphysicalexamLinkbuttonfor1997GuidelinesforEvaluation&ManagementServicesTheNewAmbulatoryEvaluationDocumentationremindersofrequirementsfortherelevantsectionLinktothe1997GuidelinesforEvaluation&ManagementServicesSeparate“yes”and“no”optionsfordocumentingpertinent
positiveandnegativeresponsesResetbuttonsDocumentationremindersofreqManyPhysiciansUnderCode!Mosthealthcareprovidersdomoreworkthantheirdocumentationsupports!
And,asthesayinggoes,ifitisn’tdocumented,itdidn’thappen!ManyPhysiciansUnderCode!MosHowMuchIsAtStake?Fact
33-52%ofpatientencountersareUNDERcoded
(JABFP2001;14:184-92andFPMOctober2003“Howtogetallthe99214syoudeserve”)DifferencesinMedicarereimbursement99214->99215=$3099214->99213=$30
Ifyousee30patientsperdayyoumaylose$300ormoreperday![33%(30patients/day)x$30/patient=$300/day]Working5days/weekfor50weeks,thatisapotentiallossof$75,000injust1yearduetoinadequatecoding!!!HowMuchIsAtStake?FactWhatIsTheGain?Decreasingbillingandcodingerrorsbyjust50%couldmeananincreaseofnearly
$40,000
peryearinpracticerevenues!
Theequivalentofseeinganadditional690patients/yearOr,anextra3patients/day!WITHOUTTHEEXTRAWORK!WhatIsTheGain?DecreasingbiBenefitsofMedicalTemplatesEasytouseLegibleFastandsimpletocompleteSavesdictationandtranscriptioncostsFastandsimpletoimplementinanypracticeStandardizesdocumentationEnhancesriskmanagementstrategiesReducestheriskofdowncodingWhendocumentationisappropriateforbillingcodeÖÖÖÖÖÖÖÖBenefitsofMedicalTemplatesEaProfessional,MedicalandLegalBenefitsLegible,thorough,andstandardizeddocumentationisaprovenstrategytoreduceriskThoroughdocumentationbecomesthestandardofcareImproved,thoroughdocumentationcansupportAuditsofBillingcodeswhencorrectcodeisbilledforlevelofdocumentationMandatoryQualityreportingPayForPerformanceQualityAssuranceprojectsMaintenanceofCertificationprojectsSelfevaluationofpracticeperformanceABIMPracticeImprovementModuleProfessional,MedicalandLegaAQuickReviewof
MedicalDocumentation
RequirementsAQuickReviewof
MedicalDocPatientEncounters
TheCentersforMedicareandMedicaidServices(CMS)haspublisheddefinitionsanddocumentationguidelinesforthekeycomponentsofamedicalencounternote,usingCPTcodes.PatientEncountersTheCenteKeyComponentsofDocumentationHistoryExamMedicalDecisionMakingCounselingCoordinationofCareNatureofPresentingProblemTime1997GuidelinesforEvaluation&ManagementServices/MLNProducts/Downloads/MASTER1.pdfKeycomponentsinselectingthelevelofE/MservicesKeyComponentsofDocumentatioTheHistoryTheHistoryHistoryComponentsandLevelsHPIROSPFSHTypeofHistoryBriefN/AN/AProblemFocusedBriefProblempertinentN/AExpandedProblemFocusedExtendedExtendedPertinentDetailedExtendedCompleteCompleteComprehensiveNewpatientevaluationsMUSThaveatleastaDetailedHistoryHistoryComponentsandLevelsHistoryofPresentIllnessEVERYencounterMUSTcontainaChiefComplaint!Preferentiallystatedinpatients’wordsElementsofHPI
Location Quality Severity Duration Timing Context Modifyingfactors AssociatedSignsandSymptomsBriefContains1-3elementslistedExtendedContains³4elementsORdiscusses3chronicorinactiveconditionsHistoryofPresentIllnessEVERReviewofSystemsConstitutionalSymptomsEyesEars,Nose,Mouth,ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary(Skin,Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/ImmunologicProblemPertinentDocumentsresponsestothesystemdirectlyrelatedtothepresentingproblemExtendedDocumentspositiveandnegativeresponsesto2-9systemsrelatedtotheproblemCompleteDocumentsallpositiveandnegativeresponsestosystemsrelatedtothepresentingproblemANDallothersystems(10ormoretotal)ReviewofSystemsConstitutionaPast,FamilyandSocialHistoryPastMedicalHistoryIllnesses,Operations,InjuriesandTreatmentsFamilyMedicalHistoryIncludeheritablediseasesandthosethatplacethepatientatincreasedriskSocialHistoryAnageappropriatereviewofpastandcurrentactivitiesPertinentDocumentatleast1itemfromANYofthe3areasItmustbedirectlyrelatedtotheproblemsidentifiedintheHPIComplete
AllinitialinpatientservicesrequireaCompletePFSHDocumentatleast1itemfromEACHofthe3areasPast,FamilyandSocialHistorTheExamTheExamRecognizedSingleOrganSystemsCardiovascularEars,Nose,Mouth,ThroatEyesGenitourinary(Female)Genitourinary(Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkinDetailedAnextendedexamoftheaffectedbodyareaororgans/organsystemandanothersymptomaticorrelatedareaComprehensiveAgeneralmulti-systemexamAcompleteexamofanorgansystemandotherrelatedbodyareasororgansystemsMostlevelsrequireaminimumofaDetailedExamRecognizedSingleOrganSystemMulti-organSystemExamDetailed³3vitalsignsBP,sittingorstandingBP,supinePulse,rateandregularityRespirationsTemperatureHeightWeight³2elements*ofatleast6organsystemsorbodyareasexaminedOR³1elementofatleast12organsystemsComprehensive³2elements*inatleast9organsystemsorbodyareas*Referto1997GuidelinesforEvaluation&ManagementServicesMulti-organSystemExamDetaileSingleOrganSystemExamDetailedDocument³12elements*(NOTEyeandPsychiatricexams)EyeandPsychexamsdocument³9elementsComprehensiveDocumentALLelements**Referto1997GuidelinesforEvaluation&ManagementServicesSingleOrganSystemExamDetailElementsofIndividualOrganSystemsConstitutionalVitalsignsGeneralappearanceofpatientNutrition,Bodyhabitus,Development,Deformities,GroomingEyesInspectionofconjunctivaeandlidsExamofpupilsandirisesOphthalmoscopicexamofopticdiscsEars,Nose,MouthandThroatExternalinspectionofearsandnoseOtoscopicexamAssessmentofhearingInspectionofnasalmucosa,septum,andturbinatesInspectionoflips,teethandgumsExamoforopharynxNeckExamofneckThyroidRespiratoryAssessmentofeffortPercussionofchestAuscultationPalpationofchestCardiovascularPalpationofheartAuscultationCarotidarteryexamAbdominalaortaexamFemoralarteriesexamPedalpulsesexamExtremitiesforedemaorvaricosities
Chest(Breasts)InspectionPalpationGastrointestinalAbdominalexamLiverandspleenexamHerniapresenceorabsenceAnus,perineum,rectumexamStoolforoccultblood1997GuidelinesforEvaluation&ManagementServicesElementsofIndividualOrganSExamelements,continuedLymphaticNeckAxillaGroinOtherMusculoskeletalGaitandstationInspection,palpationdigitsandnailsExamofbones,joints,musclesAND1ormoreInspectionorpalpationRangeofmotionandpresence/absenceofpainStabilityMusclestrengthandtoneSkinInspectionPalpationNeurologicCranialnervesDeeptendonreflexesSensationPsychiatricJudgmentandinsightOrientationtoperson,time,placeMemory,recentandremoteMoodandaffectGenitourinaryMaleScrotalcontentsPenisDigitalrectalexamofprostateglandFemaleExternalgenitaliaUrethraBladderexamCervixUterusAdnexa/parametria1997GuidelinesforEvaluation&ManagementServicesExamelements,continuedLymphaMedicalDecisionMakingMedicalDecisionMakingComplexityofMedicalDecisionMakingNumberofDiagnosesOrManagementOptionsAmountand/orComplexityofDatatobeReviewedRiskofComplicationsand/orMorbidityorMortalityComplexityofDecisionMakingMinimalMinimalorNoneMinimalStraightforwardLimitedLimitedLowLowMultipleModerateModerateModerateExtensiveExtensiveHighHighComplexityofMedicalDecisionExamplesof
Documentation
RequirementsExamplesof
Documentation
ReqInitialHospitalCareMustmeetallcriteria
99223ComprehensiveHistoryandExamHighcomplexityMedicaldecisionmaking99222ComprehensiveHistoryandExamModeratecomplexityMedicaldecisionmaking99221DetailedORComprehensiveHistoryandExamStraightforwardorLowComplexityMedicaldecisionmakingInitialHospitalCareMustmeetInitialInpatientConsultationMustmeetallcriteria99255ComprehensiveHistoryANDExamHighcomplexitymedicaldecisionmaking99254ComprehensiveHistoryANDExamModeratecomplexitymedicaldecisionmaking99253DetailedHistoryANDExamLowcomplexitymedicaldecisionmakingInitialInpatientConsultationNewOutpatientEncounter
NotaConsultMustmeetallcriteria99205ComprehensiveHistoryandExamHighcomplexitymedicaldecisionmaking99204ComprehensiveHistoryandExamModeratecomplexitymedicaldecisionmaking99203DetailedHistoryandExamLowcomplexitymedicaldecisionmakingNewOutpatientEncounter
NotaNewOutpatientConsultMustmeetallcriteria99245ComprehensiveHistoryComprehensiveExamHighcomplexitymedicaldecisionmaking99244ComprehensiveHistoryComprehensiveExamModeratecomplexitymedicaldecisionmaking99243DetailedHistoryDetailedExamLowcomplexitymedicaldecisionmakingNewOutpatientConsultMustmeeEstablishedOutpatientEncounterMustmeet2outof3criteria99215ComprehensiveHistoryComprehensiveExamHighcomplexitymedicaldecisionmaking99214DetailedHistoryDetailedExamModeratecomplexitymedicaldecisionmaking99213ExpandedProblemFocusedHistoryExpandedProblemFocusedExamLowcomplexitymedicaldecisionmakingEstablishedOutpatientEncountWehopeyoufoundthispresentationhelpful!Wearegratefultoallthepatientandknowledgeablebillingandcodingspecialistswehaveencounteredalongtheway!Wewelcomeyourcommentsat
WehopeyoufoundthispresentMedical
TemplatesMakingMedicalDocumentationSimpleandPainlessMedical
TemplatesProblemAfamiliarlament...
“NomatterhowmuchIwriteinmyhistoryandphysicalexamnote,Ineverseemtodocumentenoughtosubstantiateahighlevelencounter!”MedicaldocumentationisnotaboutHOWMUCHyouwrite!ItisaboutWHATyouwrite!ProblemAfamiliarlament...MedicalTemplates
CanHelp!MedicalTemplates
CanHelp!WhatareMedicalTemplates?StandardizedpatientencounterformsusingAdobePDFTechnologyUseasapaperformORCompleteformelectronicallyWhatareMedicalTemplates?StanMedicalTemplatesFeaturesDocumentationpromptersHCFA1997documentationguidelinesQualityremindersMedicarePQRICheckboxesSavetimeSaveenergyFillableTextBoxesEasytouseSavetimeSaveenergyTimesavedisMoneyearned!MedicalTemplatesFeaturesDocumTheNewAmbulatoryEvaluationTemplatefromMedicalTemplatesStillhaseasytousecheckboxesandfillabletextboxes!NowwithnewfeaturesROSwithseparate“yes”and“no”buttonsforeaseofdocumenting“pertinentpositiveandnegative”findings“Reset”buttonforeachsectionofROSBuiltinremindersofdocumentationguidelinesforsectionsofthehistoryandphysicalexamLinkbuttonfor1997GuidelinesforEvaluation&ManagementServicesTheNewAmbulatoryEvaluationDocumentationremindersofrequirementsfortherelevantsectionLinktothe1997GuidelinesforEvaluation&ManagementServicesSeparate“yes”and“no”optionsfordocumentingpertinent
positiveandnegativeresponsesResetbuttonsDocumentationremindersofreqManyPhysiciansUnderCode!Mosthealthcareprovidersdomoreworkthantheirdocumentationsupports!
And,asthesayinggoes,ifitisn’tdocumented,itdidn’thappen!ManyPhysiciansUnderCode!MosHowMuchIsAtStake?Fact
33-52%ofpatientencountersareUNDERcoded
(JABFP2001;14:184-92andFPMOctober2003“Howtogetallthe99214syoudeserve”)DifferencesinMedicarereimbursement99214->99215=$3099214->99213=$30
Ifyousee30patientsperdayyoumaylose$300ormoreperday![33%(30patients/day)x$30/patient=$300/day]Working5days/weekfor50weeks,thatisapotentiallossof$75,000injust1yearduetoinadequatecoding!!!HowMuchIsAtStake?FactWhatIsTheGain?Decreasingbillingandcodingerrorsbyjust50%couldmeananincreaseofnearly
$40,000
peryearinpracticerevenues!
Theequivalentofseeinganadditional690patients/yearOr,anextra3patients/day!WITHOUTTHEEXTRAWORK!WhatIsTheGain?DecreasingbiBenefitsofMedicalTemplatesEasytouseLegibleFastandsimpletocompleteSavesdictationandtranscriptioncostsFastandsimpletoimplementinanypracticeStandardizesdocumentationEnhancesriskmanagementstrategiesReducestheriskofdowncodingWhendocumentationisappropriateforbillingcodeÖÖÖÖÖÖÖÖBenefitsofMedicalTemplatesEaProfessional,MedicalandLegalBenefitsLegible,thorough,andstandardizeddocumentationisaprovenstrategytoreduceriskThoroughdocumentationbecomesthestandardofcareImproved,thoroughdocumentationcansupportAuditsofBillingcodeswhencorrectcodeisbilledforlevelofdocumentationMandatoryQualityreportingPayForPerformanceQualityAssuranceprojectsMaintenanceofCertificationprojectsSelfevaluationofpracticeperformanceABIMPracticeImprovementModuleProfessional,MedicalandLegaAQuickReviewof
MedicalDocumentation
RequirementsAQuickReviewof
MedicalDocPatientEncounters
TheCentersforMedicareandMedicaidServices(CMS)haspublisheddefinitionsanddocumentationguidelinesforthekeycomponentsofamedicalencounternote,usingCPTcodes.PatientEncountersTheCenteKeyComponentsofDocumentationHistoryExamMedicalDecisionMakingCounselingCoordinationofCareNatureofPresentingProblemTime1997GuidelinesforEvaluation&ManagementServices/MLNProducts/Downloads/MASTER1.pdfKeycomponentsinselectingthelevelofE/MservicesKeyComponentsofDocumentatioTheHistoryTheHistoryHistoryComponentsandLevelsHPIROSPFSHTypeofHistoryBriefN/AN/AProblemFocusedBriefProblempertinentN/AExpandedProblemFocusedExtendedExtendedPertinentDetailedExtendedCompleteCompleteComprehensiveNewpatientevaluationsMUSThaveatleastaDetailedHistoryHistoryComponentsandLevelsHistoryofPresentIllnessEVERYencounterMUSTcontainaChiefComplaint!Preferentiallystatedinpatients’wordsElementsofHPI
Location Quality Severity Duration Timing Context Modifyingfactors AssociatedSignsandSymptomsBriefContains1-3elementslistedExtendedContains³4elementsORdiscusses3chronicorinactiveconditionsHistoryofPresentIllnessEVERReviewofSystemsConstitutionalSymptomsEyesEars,Nose,Mouth,ThroatCardiovascularRespiratoryGastrointestinalMusculoskeletalIntegumentary(Skin,Breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergy/ImmunologicProblemPertinentDocumentsresponsestothesystemdirectlyrelatedtothepresentingproblemExtendedDocumentspositiveandnegativeresponsesto2-9systemsrelatedtotheproblemCompleteDocumentsallpositiveandnegativeresponsestosystemsrelatedtothepresentingproblemANDallothersystems(10ormoretotal)ReviewofSystemsConstitutionaPast,FamilyandSocialHistoryPastMedicalHistoryIllnesses,Operations,InjuriesandTreatmentsFamilyMedicalHistoryIncludeheritablediseasesandthosethatplacethepatientatincreasedriskSocialHistoryAnageappropriatereviewofpastandcurrentactivitiesPertinentDocumentatleast1itemfromANYofthe3areasItmustbedirectlyrelatedtotheproblemsidentifiedintheHPIComplete
AllinitialinpatientservicesrequireaCompletePFSHDocumentatleast1itemfromEACHofthe3areasPast,FamilyandSocialHistorTheExamTheExamRecognizedSingleOrganSystemsCardiovascularEars,Nose,Mouth,ThroatEyesGenitourinary(Female)Genitourinary(Male)Hematologic/Lymphatic/ImmunologicMusculoskeletalNeurologicPsychiatricRespiratorySkinDetailedAnextendedexamoftheaffectedbodyareaororgans/organsystemandanothersymptomaticorrelatedareaComprehensiveAgeneralmulti-systemexamAcompleteexamofanorgansystemandotherrelatedbodyareasororgansystemsMostlevelsrequireaminimumofaDetailedExamRecognizedSingleOrganSystemMulti-organSystemExamDetailed³3vitalsignsBP,sittingorstandingBP,supinePulse,rateandregularityRespirationsTemperatureHeightWeight³2elements*ofatleast6organsystemsorbodyareasexaminedOR³1elementofatleast12organsystemsComprehensive³2elements*inatleast9organsystemsorbodyareas*Referto1997GuidelinesforEvaluation&ManagementServicesMulti-organSystemExamDetaileSingleOrganSystemExamDetailedDocument³12elements*(NOTEyeandPsychiatricexams)EyeandPsychexamsdocument³9elementsComprehensiveDocumentALLelements**Referto1997GuidelinesforEvaluation&ManagementServicesSingleOrganSystemExamDetailElementsofIndividualOrganSystemsConstitutionalVitalsignsGeneralappearanceofpatientNutrition,Bodyhabitus,Development,Deformities,GroomingEyesInspectionofconjunctivaeandlidsExamofpupilsandirisesOphthalmoscopicexamofopticdiscsEars,Nose,MouthandThroatExternalinspectionofearsandnoseOtoscopicexamAssessmentofhearingInspectionofnasalmucosa,septum,andturbinatesInspectionoflips,teethandgumsExamoforopharynxNeckExamofneckThyroidRespiratoryAssessmentofeffortPercussionofchestAuscultationPalpationofchestCardiovascularPalpationofheartAuscultationCarotidarteryexamAbdominalaortaexamFemoralarteriesexamPedalpulsesexamExtremitiesforedemaorvaricosities
Chest(Breasts)InspectionPalpationGastrointestinalAbdominalexamLiverandspleenexamHerniapresenceorabsenceAnus,perineum,rectumexamStoolforoccultblood1997GuidelinesforEvaluation&ManagementServicesElementsofIndividualOrganSExamelements,continuedLymphaticNeckAxillaGroinOtherMusculoskeletalGaitandstationInspection,palpationdigitsandnailsExamofbones,joints,musclesAND1ormoreInspectionorpalpationRangeofmotionandpresence/absenceofpainStabilityMusclestrengthandtoneSkinInspectionPalpationNeurologicCranialnervesDeeptendonreflexesSensationPsychiatricJudgmentandinsightOrientationtoperson,time,placeMemory,recentandremoteMoodandaffectGenitourinaryMaleScrotalcontentsPenisDigitalrectalexamofprostateglandFemaleExternalgenitaliaUrethraBladderexamCervixUterusAdnexa/parametria1997GuidelinesforEvaluation&ManagementServicesExamelements,continuedLymphaMedicalDecisionMakingMedicalDecisionMakingComplexityofMedicalDecisionMakingNumberofDiagnosesOrManagementOptionsAmountand/orComplexityofDatatobe
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