Medical Templates Making Medical Documentation Simple And Painless

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Physician designed medical documentation tools

MedicalMedicalTemplatesTemplates

Making Medical Documentation Simple and Painless

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!

MedicalTemplatesMedicalTemplatesCan Help!Can Help!

What are MedicalTemplates?What are MedicalTemplates?

Standardized patient encounter forms using

Adobe PDF TechnologyUse as a paper form

ORComplete form electronically

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!

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

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

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!

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!!!

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!

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

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

A Quick Review of A Quick Review of Medical DocumentationMedical Documentation

RequirementsRequirements

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.

Key Components of DocumentationKey Components of Documentation

History

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

The HistoryThe History

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

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

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)

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

Complete All initial inpatient services require a Complete PFSHDocument at least 1 item from EACH of the 3 areas

The ExamThe Exam

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

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

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

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

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

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

Medical Decision MakingMedical Decision Making

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

Examples ofExamples ofDocumentation Documentation Requirements Requirements

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

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

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

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

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

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

Medical Templates Making Medical Documentation Simple And Painless

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