歐美醫(yī)藥行業(yè)模板課件

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?DecreasingbiBenefitsofMedicalTemplatesEasytouseLegibleFastandsimpletocompleteSavesdictationandtranscriptioncostsFastandsimpletoimplementinanypracticeStandardizesdocumentationEnhancesriskmanagementstrategiesReducestheriskofdowncodingWhendocumentationisappropriateforbillingcode????????BenefitsofMedicalTemplatesEaProfessional,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

NotaConsultMustmeetallcriteria99205ComprehensiveHistoryandExamHighcomplexitymedicaldecisionmaki