Medical

Templates
Making Medical Documentation
Simple and Painless

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 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!

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 MedicalTemplates
Can Help!

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 What are MedicalTemplates?
Standardized patient encounter forms using
Adobe PDF Technology
Use as a paper form
OR
Complete form electronically

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 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!

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 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

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Physician designed medical documentation tools
 Linktotothe
the1997
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
Link

Separateyes
yesand
andno
nooptions
optionsfor
fordocumenting
documenting
Separate
pertinent positive and negative responses
pertinent positive and negative responses
Resetbuttons
buttons
Reset

Documentationreminders
remindersofofrequirements
requirementsfor
forthe
therelevant
relevantsection
section
Documentation
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Many Physicians Under Code!
Most healthcare providers do more work than their
documentation supports!
And, as the saying goes,
if it isnt documented, it didnt happen!

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 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?
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 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 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

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 A Quick Review of
Medical Documentation
Requirements

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 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.

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 Key Components of Documentation
History Key components in
selecting the level of
Exam E/M services

Medical Decision Making

Counseling
Coordination of Care
Nature of Presenting Problem
Time
1997Guidelines
1997 Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf
http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf

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 The History

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 History Components and Levels
HPI ROS PFSH Type of History
Brief N/A N/A Problem Focused

Brief Problem N/A Expanded

pertinent 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 Illness
EVERY encounter MUST contain a Chief Complaint!
Preferentially stated in patients words

Elements of HPI
Location Brief
Brief
Quality Contains1-3
Contains 1-3elements
elementslisted
listed
Severity Extended
Extended
Duration 4elements
Contains4
Contains elements
Timing ORdiscusses
OR discusses33chronic
chronicor orinactive
inactiveconditions
conditions
Context
Modifying factors
Associated Signs and Symptoms

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 Review of Systems
Constitutional Symptoms
ProblemPertinent
Problem Pertinent
Eyes Documentsresponses
responsestotothe
thesystem
system
Documents
Ears, Nose, Mouth, Throat directlyrelated
directly relatedto
tothe
thepresenting
presenting
Cardiovascular problem
problem
Respiratory
Extended
Extended
Gastrointestinal
Documentspositive
Documents positiveand
andnegative
negative
Musculoskeletal responsestoto2-9
2-9systems
systemsrelated
relatedto
to
responses
Integumentary (Skin, Breast) theproblem
the problem
Neurological
Psychiatric Complete
Complete
Documentsall
Documents allpositive
positiveandandnegative
negative
Endocrine responsesto tosystems
systemsrelated
relatedtotothe
the
responses
Hematologic/Lymphatic presentingproblem
presenting problemAND ANDall allother
other
Allergy/Immunologic systems(10
systems (10orormore
moretotal)
total)

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 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
Pertinent
Documentatatleast
Document least11item
itemfrom
fromANYANYofofthe
the33areas
areas
ItItmust
mustbe
bedirectly
directlyrelated
relatedtotothe
theproblems
problemsidentified
identifiedininthe
theHPI
HPI

Complete
All initial inpatient services require a Complete PFSH
Document at least 1 item from EACH of the 3 areas
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 The Exam

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 Recognized Single Organ Systems
Cardiovascular
Ears, Nose, Mouth, Throat Detailed
Detailed
Eyes Anextended
An extendedexam
examofofthe
theaffected
affectedbody
bodyarea
area
Genitourinary (Female) ororgans/organ
or organs/organsystem
systemand
andanother
another
symptomaticor
symptomatic orrelated
relatedarea
area
Genitourinary (Male)
Hematologic/Lymphatic/Immunologic
Musculoskeletal Comprehensive
A general multi-system exam
Neurologic A complete exam of an organ system and
Psychiatric other related body areas or organ systems
Respiratory
Skin Most levels require a minimum of a Detailed Exam
Most levels require a minimum of a Detailed Exam

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 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

*Refertoto1997
*Refer 1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services

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 Single Organ System Exam
Detailed
Document 12 elements* (NOT Eye and Psychiatric exams)
Eye and Psych exams document 9 elements

Comprehensive
Document ALL elements*

*Refertoto1997
*Refer 1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services

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 Elements of Individual Organ Systems
Constitutional Cardiovascular
Vital signs Palpation of heart
General appearance of patient Auscultation
Nutrition, Body habitus, Development, Deformities,
Grooming
Carotid artery exam
Eyes Abdominal aorta exam
Inspection of conjunctivae and lids Femoral arteries exam
Exam of pupils and irises Pedal pulses exam
Ophthalmoscopic exam of optic discs Extremities for edema or varicosities
Ears, Nose, Mouth and Throat Chest (Breasts)
External inspection of ears and nose Inspection
Otoscopic exam Palpation
Assessment of hearing Gastrointestinal
Inspection of nasal mucosa, septum, Abdominal exam
and turbinates Liver and spleen exam
Inspection of lips, teeth and gums Hernia presence or absence
Exam of oropharynx Anus, perineum, rectum exam
Neck Stool for occult blood
Exam of neck
Thyroid 1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
1997
Respiratory
Assessment of effort
Percussion of chest
Auscultation
Palpation of chest
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 Exam elements, continued
Lymphatic Psychiatric
Neck Judgment and insight
Axilla Orientation to person, time, place
Groin Memory, recent and remote
Other Mood and affect
Musculoskeletal Genitourinary
Gait and station
Inspection, palpation digits and nails Male
Exam of bones, joints, muscles AND 1 Scrotal contents
or more Penis
Inspection or palpation Digital rectal exam of prostate gland
Range of motion and
presence/absence of pain
Stability Female
Muscle strength and tone External genitalia
Skin Urethra
Inspection Bladder exam
Palpation Cervix
Neurologic Uterus
Cranial nerves Adnexa/parametria
Deep tendon reflexes
1997Guidelines
Guidelinesfor
forEvaluation
Evaluation&&Management
ManagementServices
Services
Sensation 1997

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Medical Decision Making

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 Complexity of Medical Decision Making
Number of Amount and/or Risk of Complexity of Decision
Diagnoses Complexity of Data to Complications Making
Or Management be Reviewed and/or Morbidity
Options or Mortality

Minimal Minimal or None Minimal Straightforward

Limited Limited Low Low

Multiple Moderate Moderate Moderate

Extensive Extensive High High

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 Examples of
Documentation
Requirements

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 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

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 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

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 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

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 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

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 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

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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

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