December 15, 2008

COPD Evaluation Medical Template Revised

Our COPD Evaluation MedicalTemplate (Consult note or H&P) has been revised to give expanded space to document a review of systems, assessment and plan, history, and has improved documentation reminders.

When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service, including critical care.

The COPD Evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a H&P or Consult.

History Click here to learn about History Documentation

    • Chief complaint
    • History of present illness
    • COPD symptoms and severity checklist
    • Past medical and surgical history
    • Social history
      • Risk factors for COPD and other respiratory diseases (occupational exposure, smoking, and others)
    • Family history
    • Review of systems
      • Yes/No checkboxes for clear and complete documentation

Examination Click here to learn about Physical Exam Documentation

    • When completed, represents a comprehensive (highest) level physical exam as defined in 1997 Guidelines.
    • Checkboxes for pertinent negatives and common positive findings

Medical Decision Making Click here to learn about MDM Documentation

    • Full page for adequate space with complex patients
    • Easy Documentation with checkboxes
      • Review of labs, tests, imaging, old records
      • Coordination of care
      • Common diagnostic and therapeutic options
    • Assessment and plan


Chronic Obstructive Pulmonary Disease Evaluation

www.e-medtools.com COPD Evaluation Patient Name Review of Systems Yes Constitution Fatigue Malaise Fever or chills Appetite changes ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Urinary changes Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rashes Sensitivity to sun Neurologic Headaches Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Sinus problems Recurrent infections No Reset DOB Chief complaint/Reason for consult Date Start time Referring Healthcare Provider Stop time www.e-medtools.com History of Present Illness COPD Symptom Asymptomatic with usual activity Patient is Nonverbal. History obtained from FEV1/FVC >/=70% <70%>80% >79% SEVERITY Family Medical records Chronic Bronchitis symptoms Increased cough Increased dyspnea or wheeze Increased sputum production Change in sputum color/quality Reset At risk Mild Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest Reset 50-79% Moderate 30-49% Severe <30%> lb lying / Obese kg Temp standing Grooming appropriate P rate / Reg R Irreg Sats % BP sitting General ENT Neck Cachectic Unkempt appearance Nasal mucosa Dental caries Dentition Gingivitis Oropharynx Mallampati I II III IV Oral Petechiae Oropharyngeal edema or erythema No JVD JVD present Oral ulcers www.e-medtools.com Thyromegaly Thyroid nodules palpable Erythema consistent with radiation dermatitis Normal to palpation Thyroid Neck mass ______________________________ Scarring consistent with old, healed radiation dermatitis No respiratory distress No chest wall defects Resp Clear to auscultation Decreased fremitus Dullness to percussion Bronchial breath sounds Rales Egophony (E to A change) Rhonchi Wheezes Accessory respiratory muscle use Erythema consistent with radiation dermatitis Scarring consistent with old, healed radiation dermatitis Peripheral pulses palpable III IV V No peripheral edema Absent Weak CV GI Clear S1 S2 Murmur No murmur Systolic No gallop No rub I II www.e-medtools.com No palpable masses Hepatomegaly Diastolic Grade VI Peripheral pulses Splenomegaly Liver and spleen not palpable No hepatojugular reflux Diagnostic Data \____/ / \ ____ / ____ / ____ / \ \ \ Lymph Musc Extrem Skin Neuro No lymphadenopathy Lymphadenopathy Increased Neck Axilla Groin Other ______________________ Muscle tone within normal limits Gait within normal limits No clubbing Clubbing Decreased Shuffle Synovitis Rt Lt _______________________ Ataxia Wide based Cyanosis No cyanosis No rashes, ecchymoses, nodules, ulcers Oriented to person, time, place, situation Affect Periungual telangiectasias 58(Pts with CABP) Splinter hemorrhages Person Time Place NOT ORIENTED to ©MB and RR 2006-2008 Revised13Oct08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services www.e-medtools.com COPD Evaluation Patient Name Plan Impression 52 DOB Date Start time Stop time COPD Therapy PRN albuterol “rescue agent” Inhaled corticosteroids Oral steroids Intravenous steroids Long-acting beta agonist Theophylline Long-acting anti-cholinergic Antibiotics for exacerbations Smoking cessation aids Long term oxygen therapy Patient advised to quit smoking Patient advised of risks of alcohol, narcotic and benzodiazepine use Medication Side Effects discussed 52 If no history of glaucoma or urinary retention Patient has completed advanced health care directives 47 HCPOA is Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION www.e-medtools.com Mental status changes OR 2 of the following Dyspnea at rest Respiratory rate > 25 Severe COPD exacerbation requiring hospitalization as evidenced by Pulse > 100 Accessory respiratory muscle use 52 www.e-medtools.com Schedule Patient For Bronchoscopy Pulmonary Function Testing Methacholine Challenge 6 Minute Walk Test Bone density evaluation CXR Chest CT 12 lead ECG ECHO with bubble study assess PA pressures Cardiopulmonary Stress Test Sleep Study CT Surgery eval for lung reduction Pulmonary Rehabilitation Pneumococcal vaccine Influenza vaccine with contrast www.e-medtools.com www.e-medtools.com Signature cc Continuous home oxygen therapy Flow rate _______L/min Oxygen concentrator Oxygen tank with conservation valve Nasal cannula with reservoir Portable oxygen tank Gas Liquid Supplemental oxygen therapy during air travel Flow rate _______L/min Home CPAP Flow rate _______ L/min Heater and humidifier Mask type Nasal Oronasal Face Home BiPAP Inspiratory flow _______/Expiratory flow _______ Heater and humidifier Mask type Nasal Oronasal Face ER Notes Old Chart EMS Note ECG Nursing Notes & Vitals log Case Management Labs X Rays MRI Pharmacy US CT Labs CBC BMP CMP BNP LFTs Alpha 1 antitrypsin Cultures Blood Sputum Other www.e-medtools.com Data Reviewed Care Coordinated With ER MD HCPOA Primary Care MD Social Worker ©MB and RR 2006-2008 Revised13Oct08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services

December 8, 2008

OpenMedSpel for OpenOffice.org 3.0

OpenMedSpel has been updated for OpenOffice.org 3.0 and higher, and is listed on OpenOffice.org Extensions!.

OpenMedSpel
includes nearly 50,000 medical terms ranging from abdominis to zygomatic, which allows you to concentrate on your work instead of looking up words in a medical dictionary that are not in the built-in USA English OpenOffice.org spelling dictionary.

OpenMedSpel is free and open source medical spelling software released under a GPL license.


Download OpenMedSpel for OpenOffice.org


OpenOffice.org Extentions - OpenMedSpel

November 10, 2008

Medical Decision Making Calculator - Google Desktop

e-MedTools released a free Medical decision making calculator for Google Desktop.

Medical decision making (MDM) is a required component for all Evaluation and Management services (E&M), which include most clinic and hospital patient encounters.

This calculator is an excellent learning tool for clinicians that want to improve the accuracy of billing for E&M services,
and is based on the MDM assessment method used by most Medicare carriers nationwide.




Health care providers working in Delaware, Maryland, Texas, Virginia, or the District of Columbia should use the method developed by TrailblazerHealth (the Medicare carrier in the states mentioned above) to evaluate the Medical Decision Making portion of the E&M service, which is not included in the current version of this calculator.

November 2, 2008

Pulmonary Hospital H&P or Consult Note Updated

Our Pulmonary/Critical Care Hospital H&P or Consult note has been revised to give expanded space to document an assessment and plan, history, and has improved documentation reminders.

When completed, and in conjunction with a supporting level of medical decision making, this MedicalTemplate meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service, including critical care.

The pulmonary/critical care new patient evaluation MedicalTemplate contains prompters and space for all the required elements for a E&M encounter such as a H&P or Consult.

History Click here to learn about History Documentation

    • Chief complaint
    • History of present illness
    • Past medical and surgical history
    • Social history
      • Risk factors for respiratory disease (occupational exposure, smoking, and others)
    • Family history
    • Review of systems
      • Yes/No checkboxes for clear and complete documentation

Examination Click here to learn about Physical Exam Documentation

    • When completed, represents a comprehensive (highest) level physical exam as defined in 1997 Guidelines.

Medical Decision Making Click here to learn about MDM Documentation

    • Full page for adequate space with complex patients
    • Easy Documentation with checkboxes
      • Review of labs, tests, imaging, old records
      • Coordination of care
      • Common diagnostic and therapeutic options
    • Assessment and plan
Follow this link for a concise review of the medical documentation requirements for E&M services.



Pulmonary / Critical Care New Patient Evaluation

Pulmonary Evaluation Date Time Yes Constitution Fatigue Malaise Fever or chills Appetite changes Eyes Vision changes New pain Scotomas ENT/mouth Nose bleed Dental caries Dental abscesses Jaw pain Respiratory Dyspnea Cough Phlegm Hemoptysis Wheeze Cardiovascular Chest pain Diaphoresis Ankle edema Syncope Palpitations Gastrointestinal Nausea or vomiting Weight changes Constipation or Diarrhea Abdominal pain Genitourinary Urinary changes Hematuria Dysuria Urethral discharge Musculoskeletal Myalgias Arthralgias Joint swelling Recent trauma Skin/Breasts Masses New skin lesions Rashes Sensitivity to sun Neurologic Headaches Seizures Muscle weakness Endocrinologic Hair loss Polydipsia Tremors Neck pain Heme/Lymph Bleeding gums Unusual bruising Swollen lymph nodes Allergy/Immunology Sinus problems Recurrent infections Psychologic Mood changes Agitation Hallucinations Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________ Chief complaint/Reason for consult No Reset www.e-medtools.com Referring MD History of Present Illness Patient is Nonverbal. History obtained from Family Medical records Elements of HPI: Location, quality, severity, timing, duration, context, modifying factors, associated signs and symptoms Reset www.e-medtools.com Reset Reset Medications Medications reviewed Medications reconciled with Nursing Home or Hospital discharge Information Allergies Allergy List reviewed 46 No food or drug allergies Past Medical, Family Social History Reset www.e-medtools.com Asthma Cerebral Artery Disease Bronchiectasis Congestive Heart Failure COPD Coronary Artery Disease COP (BOOP) Diabetes Cystic Fibrosis GERD Histiocytosis Hepatic Dysfunction Tuberculosis HIV/AIDS PAH Hypertension Sarcoidosis Inflam bowel disease Wegener’s Malignancy Obstructive Sleep Apnea CPAP BiPAP Malignancy Adrenal Colon Melanoma Renal cell Reset Reset www.e-medtools.com Thyroid Neuromuscular weakness Occupational exposures Osteoporosis Pancreatitis Peripheral Artery Disease Scleroderma Seizure Disorder Sjogren’s Renal dysfunction/ failure Rheumatoid Arthritis Thrombotic Disease Thyroid disease Breast Lung Chemotherapy Colonoscopy ECHO/Stress Test Mammogram PFTs PapSmear Prior Intubations Radiation exposure Sleep Study Steroid use Prostate Testicular Surgeries Reset Social History / Risk factors Denies Denies Denies Yes Ever smoker ___ # Packs X ____ # Yrs Yes Chews tobacco Yes Quit tobacco use Quit date _________ Patient is unwilling to quit Patient willing to consider quitting Patient quit, but resumed smoking Patient willing to quit within 1 month Yes Yes Yes Yes Feels safe at home or work Tattoos High risk sexual behavior Recreational drug use Inhalational Injectable Denies Reset Yes Patient has tried smoking cessation aids Nicotine replacement Buproprion or nortriptyline Nicotine receptor blockade Reset www.e-medtools.com Denies Denies Denies Denies Denies Ingestible Reset Denies Denies Denies Denies Denies Yes Yes Yes Yes Yes Alcohol use ___ Drinks per day week Felt the need to cut down on drinking? Annoyed by others criticizing drinking? Guilt associated with drinking? Eye opener needed? Yes Drug dependence Narcotics Benzodiazepines Occupational and Exposure History Reset www.e-medtools.com Reset Inorganic dusts i.e., quarries, sandblasting, cement, stone carving, welding, plumbing, shipyard work, firefighter Organic dusts i.e., farming, building inspection, woodworking, remodeling, handling vegetable matter or animals Noxious fumes i.e., spray painting, autobody work, working with dyes or glues, manufacturing plastic Hot tub or Jacuzzi or High Pressure washings Pets or feathers Chemicals or fires Family Medical History Reset Asthma CHF COPD Coronary Artery Dis Thrombotic disorder Thyroid Disease Malignancy in first degree relatives, specify Pancreatitis Peripheral Artery Disease Renal Dysfunction ©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Pulmonary Evaluation Exam Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________ General Multisystem requires performing ALL of ≥9 organ systems, AND ≥2 elements documented in each organ system www.e-medtools.com Height ___________ in cm To qualify as a comprehensive exam: Respiratory Single Organ System Exam requires documentation of ALL highlighted organ system elements, AND ≥1 element in every other organ system is expected lb kg Regular Irregular Ventilator, IV Medications & Labs Ventilator Mode PRVC Rate AC SIMV PC Constitutional (≥ 3 vitals) Body habitus and Grooming required of General Multisystem but not Organ System Exam Weight ___________ Pulse Rate __________ Temperature __________ AND Rhythm Other ____________ __________ www.e-medtools.com Blood Pressure lying Respiratory Rate__________ Body habitus wnl Cachectic Unkempt Obese Blood Pressure sitting __________ / __________ OR standing __________ / __________ __________ / __________ Optional Sats _____ % Cardiac Output _____ SVR _____ Tidal Vol __________ PEEP PS FiO2 __________ __________ __________ ENT Grooming wnl Nasal mucosa, septum, and turbinates wnl PO2/FiO2__________ Plateau __________ NonInvasive Ventilator CPAP BiPAP Dentition and gums wnl Oropharynx wnl Dental caries Gingivitis Oral ulcers Oral Petechiae www.e-medtools.com Mallampati Oropharyngeal edema or erythema I II III IV Neck Neck wnl Thyroid wnl Dose Rate Erythema or scarring consistent with Thyromegaly Recent Old radiation dermatitis Neck mass ___________________________ Thyroid nodules palpable IV Medications Pressors Jugular Veins wnl JVD present a, v or cannon a waves present ____________________________ ____________________________ Antihypertensives Resp Chest is free of defects, expands normally and symmetrically Erythema consistent with radiation dermatitis Scarring consistent with old, healed radiation dermatitis Respiratory effort is wnl Accessory respiratory muscle use Intercostal retractions ____________________________ Diuretics ____________________________ Antibiotics www.e-medtools.com Chest percussion wnl Tactile exam wnl Dullness to percussion Tactile fremitus Increased Clear to auscultation Bronchial breath sounds Rub present ________________________ Paradoxic diaphragmatic movements Lt Rt Hyperresonance Lt Rt ____________________________ ____________________________ Sedation Decreased _____________________________________ Egophony (E to A) Rales Rhonchi Wheezes ____________________________ Narcotics CV Clear S1 S2 Murmur present No murmur, rub or gallop Systolic Gallop I Rub II III IV V VI Weak Pulsatile Diastolic Grade No peripheral edema LUQ RUQ Liver Axilla Groin ____________________________ Heparin Peripheral pulses palpable Peripheral pulses LLQ Absent ____________________________ Insulin GI ____________________________ Antiarrhythmics www.e-medtools.com Lymph node exam wnl Areas examined Lymphadenopathy noted in Neck Axilla Abdominal exam wnl Mass present RLQ ____________________ Liver Spleen ____________________________ Steroids Liver and spleen palpation wnl Unable to palpate Lymph (≥2 areas must be examined) Neck Spleen Enlarged Groin Other ___________________ ____________________________ Paralytic Other ___________________ Musc Muscle tone within normal limits, and no atrophy noted Tone is Increased Decreased Atrophy present ____________________________ Thrombolytic ____________________________ TPN Gait and station wnl Labs \____/ / \ ____ / ____ / ____ / \ \ \ www.e-medtools.com Extrem Skin No rashes, ecchymoses, nodules, ulcers Exam wnl Clubbing Cyanosis Ataxia Wide based gait Shuffle Patient leaning Petechiae Synovitis Rt Rt Lt Front Back Lt ________________________ Splinter hemorrhages Person Depressed Time Place Periungual telangiectasias Neuro Oriented 58(Pts with Community Acquired Bacterial Pneumonia) NOT oriented to Anxious Affect is within normal limits OR Patient appears Glasgow Coma Score E _____ V _____ M _____ Agitated APACHE II Score __________ ©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Pulmonary Evaluation Data Reviewed ER Notes Old medical records Labs Radiology data ECHO ECG Stress Test Pulmonary Function Test Nursing Notes/Vitals log Patient _________________________________________ DOB _____ / _____ / _____ MRN _____________________ Impression Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION Patient has completed advanced health care directives 47 HCPOA is _______________________________________ www.e-medtools.com www.e-medtools.com Care Coordinated with Patient HCPOA / Surrogate PCP Consultant Case Management or Social Worker Pharmacy Nursing Physical Therapist Occupational Therapist Speech Therapist www.e-medtools.com Recommended Actions Aggressive pulmonary toilet DVT prophylaxis Stress ulcer prophylaxis Daily sedation vacation and neurologic assessment Head of bed elevated > 30 Degrees at all times Intense glycemic control Insulin infusion Central line change or removal (send tip for culture) Physical therapy Enteral/Parenteral feeds Smoking cessation aids Pneumonia vaccine prior to discharge Influenza vaccine prior to discharge www.e-medtools.com Recommended Diagnostics PPD Testing 12-lead EKG Echocardiogram Sputum culture Bacterial Blood culture Urine culture CSF culture CBC with differential PT, PTT, INR BMP (with calcium) HIV Hepatitis panel Fungal AFB www.e-medtools.com www.e-medtools.com Signature ________________________________________ cc __________________________________ ©MB and RR 2006-2008 Revised 31Oct08 e-medtools.com Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Completion of this form meets or exceeds the documentation requirements in the 1997 Guidelines for Evaluation & Management Services Pulmonary and Critical Care New Patient Evaluation Template Definitions Sepsis Positive blood culture AND Heart rate >⁄= 90 Temp <⁄= 36 C or >⁄= 38 C Resp rate >⁄= 20 OR PCO2 <⁄= 32 on ABG WBC <⁄=4000 OR >⁄= 12000 OR >⁄= 10% Bands Without a positive blood culture, the above findings are consistent with Systemic Inflammatory Response Syndrome (SIRS) www.e-medtools.comStart time Date Stop time Physiologic Score Temp ______ HR MAP RR Oxygenation >181 <40>49 <6>105.7 93.2-96.7 Heart Rate 70-109 n/a 110-139 140-179 >161 55-69 40-54 <>70 130-139 61-70 150-154 155-159 120-129 2.5-2.9 200-349 130-159 35-49 Serum Na Serum K Severe Sepsis The patient must meet the above criteria AND have hypotension, hypoperfusion or organ dysfunction. Hypotension is defined as SBP <>/= 40 mmHg Oxygenation If FiO2 > 49%, A-a If FiO2 <>500 <54>179 <>7.1 <>3.4 >7.69 <7.15>39 <1.0>59 <20 score =" 15" score =" Acute" 45 ="0" 54 =" 2" 64 =" 3" 74 =" 5">74 =6 Age Score ______ Predicted Mortality Based on APACHE II Score Score 5-9 10-14 15-19 20-24 25-29 30-34 over 34 Interpretation ~4% death rate ~8% death rate ~15% death rate ~25% death rate ~40% death rate ~55% death rate ~75% death rate ~85% death rate Ventilator Strategies (www.ihi.org) www.e-medtools.com 4 5 15-29 <15>/= 30 degrees Stages of chronic kidney disease 2. Daily sedation vacation AND Stage GFR (mL/min/1.73m2 ) Action assessment of ability to wean from 1 >89 Diagnosis and treatment. Treat comorbid conditions. Slow progression. ventilator 2 60-89 Estimate progression 3. Stress ulcer prophylaxis 3 38-59 Evaluate and treat complications 4. Deep Venous Thrombosis prophylaxis Oxygen Coverage PO2<⁄=55 OR Sats <⁄=90% PO2 56-59 OR Sats 89% WITH CHF Cor pulmonale P wave >2mm lead II, III or AVF Hct >56% Sats <⁄=88% for >5 minutes during sleep NOT COVERED PO2 >59 OR Sats >89% The National Kidney Foundation recommends estimating GFR by use of the Cockcroft-Gault or MDRD equations General Acid-Base Rules Acidosis Acute Resp ∆pH = -0.008 x ∆PCO2 ∆HCO3 = 0.1 x ∆PCO2 (+/-3) www.e-medtools.com Chronic Resp PCO2 = 2.4(HCO3) – 22 ∆HCO3 = 0.35 x ∆PCO2 (+/-4) Metabolic PCO2 = 1.5(HCO3) + 8 +/-2 PCO2 ~ last 2 digits pH ∆PCO2 = 1.2 x ∆HCO3 Alkalosis ∆pH = 0.008 x ∆PCO2 ∆HCO3 = -0.2 x ∆PCO2 (usually not to less than 18 mEq/L) ∆HCO3 = -0.4 x ∆PCO2 (usually not to less than 18 mEq/L) PCO2 = 0.9(HCO3) + 9 +/-2 ∆PCO2 = 0.6 x ∆HCO3 ©MB and RR 2006, 2007 Revised 13Nov07 www.e-medtools.com Indicates 2007 Physician Quality Reporting Initiative (PQRI) Physician Quality Measures

October 30, 2008

E & M Coding/Audit Worksheet in Aqua/Grey

The E&M Coding and Audit Worksheet developed by The Lung Doctor is now available in a Aqua and Grey color scheme for better appearance when printed. The key (and required!) components of history, exam, and medical decision making are broken down for each level of E&M service in this worksheet. Medical decision making is quantified by the method used by most Medicare carriers nationwide.


Patient Facility DOB Encounter Date Chief Complaint is required in ALL documentation Criteria Status of 1-2 Chronic Conditions OR Status of 1-2 Chronic Conditions OR MRN History Components HPI (History of Present Illness) Status of 3 chronic problems 1 2 3 Status of 3 Chronic Conditions OR Status of 3 Chronic Conditions OR Choose Elements Quality Location Duration Severity Timing Context Modifying factors Associated Signs/Symptoms ROS (Review of Systems) Constitutional ENT Eyes CV Skin/Breasts Resp Endo GI GU Heme/Lymph MS Neuro Psych Allergy/Immunology PFSH (Past Medical, Family Social History) Past History (Illnesses, Surgeries, Injuries) Past Family (Diseases, Hereditary illnesses) Social (Review of current, past activities) *Complete PFSH 3 history areas for ALL NEW Patients 2 history areas for ALL Follow Up/Established Visits OR Patients seen in Emergency Department OR Brief 1-3 Elements Brief 1-3 Elements Pertinent to Problem Extended ≥4 Elements Extended (Pertinent to problem and other related systems) 2-9 Total Extended ≥4 Elements Complete (Pertinent and all related systems) NA 1 NA NA 10 Total Pertinent *Complete 1 Area PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED 2-3 Areas COMPREHENSIVE ALL Criteria for selected level MUST be MET or EXCEEDED Examination Exam description Limited to affected body area or organ system Affected body area/organ system and other symptomatic or related organ systems Extended exam of affected body areas/organ systems and other symptomatic or related organ systems General Multi-System Complete Single Organ System 1995 Guideline 1997 Guideline Type of Exam 1 Body Area or Organ System 1-5 Bulleted Items PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED 6-11 or more 2-7 12-17 or more for 2 or more systems 18 or more for 9 or more systems Refer to Guideline 2-7 ≥8 Not Defined DETAILED COMPREHENSIVE See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements 1 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN A. Complexity of Medical Decision Making Number of Diagnoses or Treatment Options Problem (Status) Self-limited or minor (stable, improved or worsening) Est. problem (to examiner) stable, improved Est. problem (to examiner) worsening New problem (to examiner) no additional workup planned New problem (to examiner) additional workup planned MDM = Medical Decision Making (Number x Number Max = 2 Max = 1 Check corresponding box below on Line A Final Result for Complexity of MDM Points Points 1 1 2 3 4 Total = Result) Result B. Amount and/or Complexity of Data Reviewed Reviewed Data Review and/or Order of lab tests Review and/or Order of tests in the radiology section of CPT Review and/or Order of tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider Independent visualization of image, specimen or tracing (NOT simply review of report) Points 1 1 1 1 1 2 2 Check corresponding box below on Line B of Final Result for Complexity of MDM MDM = Medical Decision Making TOTAL C. Risk of Complications, Morbidity and/or Mortality Risk Min Choose highest risk level and select corresponding risk level on line B in Final Result for Complexity Presenting problems Dx procedures ordered Management options 1 minor or self-limited Venipuncture, CXR, EKG, EEG Rest, elastic bandages 2 or more minor 1 stable chronic problem Acute uncomp illness/injury Mild exac  1 chron prob Physiol tests NOT under stress Non CV imaging with contrast Superficial needle biopsies Physiologic tests under stress Dx endoscopies NO risk factors Deep needle or incisional bx CV imaging + contrast Obtain fluid from body cavity CV imaging + contrast, risk factors Card electrophysiologic studies Dx endoscopies + risk factors Discography OTC drugs, PT, OT IV fluids without additives Minor surgery NO risk factors Minor surgery + risk factors Mod Elective major surgery 2 stable chron prob Prescription drug therapy Acute illness + systemic Sx Therapeutic nuclear medicine Acute complicated injury IV fluids + additives Elective maj surg + risk factors High Sev exac, 1 chron prob Emergency major surgery Acute or chronic illness Parenteral controlled sub posing threat to life/limb Rx requiring intense monitoring Abrupt change neuro status DNR or de-escalation of care Check corresponding box below on Line C of Final Result for Complexity of MDM Low Final Result for Complexity of Medical Decision Making The column with 2 or 3 circles determines overall complexity of Medical Decision Making A B C Number Tx Options See TOTAL above in Box A Amount of Data See TOTAL above in Box B Highest Risk See Box C Above 1 or less Minimal 1 or less Minimal Minimal 2 Limited 2 Limited Low 3 Multiple 3 Multiple Moderate 4 Extensive 4 Extensive High Decision Making Level SF Low Moderate High 2 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN OVERALL OUTPATIENT ENCOUNTER LEVEL New Office / Consult / ER History Exam Complexity Medical Decision LEVEL Requires 3 components within shaded area PF EPF D C ER: PF ER: EPF ER: EPF ER: D PF EPF D C ER: P ER: EPF ER: EPF ER: D SF SF L M ER: SF ER: L ER: M ER: M C ER: C C ER: C H ER: H Established Office Requires 2 components within shaded area Minimal PF EPF D problem that may PF EPF D not require SF L M presence of physician C C H I II III IV V I II III IV V PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity OVERALL INPATIENT ENCOUNTER LEVEL History Exam Complexity Medical Decision LEVEL Initial Hosp Encounter or Observation D or C C C D or C C C SF / L M H I II III Subsequent Inpatient or Follow Up PF EPF D PF EPF D SF / L M H I II III PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity Time If ALL responses regarding time are “Yes”, billing may be based on Time “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Must be face-to-face (Outpatient or Inpatient) Does documentation discuss the content of counseling or coordination of care? Does documentation reveal that more than half the time was spent on counseling or coordination of care? □Yes □No □Yes □No □Yes □No References 1997 Guidelines for Evaluation and Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf HGSAdministrators Documentation Worksheet www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf Evaluation and Management Coding and Documentation Reference Guide Trailblazer Health Enterprises, LLC 3 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates

October 29, 2008

Demystifying Medical Documentation


Medical Templates Demystifying Medical Documentation Created by The Lung Doctor for e-Medtools A Quick Review of Medical Documentation Requirements Created by The Lung Doctor for e-Medtools 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. Created by The Lung Doctor for e-Medtools Key Components of Documentation History Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time Created by The Lung Doctor for e-Medtools Key components in selecting the level of E/M services 1997 Guidelines for Evaluation & Management Services 1997 Guidelines for Evaluation & Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf The History Created by The Lung Doctor for e-Medtools History Components and Levels HPI Brief Brief Extended Extended ROS N/A Problem pertinent Extended Complete PFSH N/A N/A Pertinent Complete Type of History Problem Focused Expanded Problem Focused Detailed Comprehensive New patient evaluations MUST have at least a Detailed History Created by The Lung Doctor for e-Medtools History of Present Illness EVERY encounter MUST contain a Chief Complaint! Preferentially stated in patients’ words Elements of HPI Location Brief Brief Quality Contains 1-3 elements listed Contains 1-3 elements listed Severity Extended Duration Extended Contains ≥ 4 elements Timing Contains ≥ 4 elements OR discusses 3 chronic or inactive conditions OR discusses 3 chronic or inactive conditions Context Modifying factors Associated Signs and Symptoms Created by The Lung Doctor for e-Medtools Review of Systems Constitutional Symptoms Eyes Ears, Nose, Mouth, Throat Cardiovascular Respiratory Gastrointestinal Musculoskeletal Integumentary (Skin, Breast) Neurological Psychiatric Endocrine Hematologic/Lymphatic Allergy/Immunologic Problem Pertinent Problem Pertinent Documents responses to the system Documents responses to the system directly related to the presenting directly related to the presenting problem problem Extended Extended Documents positive and negative Documents positive and negative responses to 2-9 systems related to responses to 2-9 systems related to the problem the problem Complete Complete Documents all positive and negative Documents all positive and negative responses to systems related to the responses to systems related to the presenting problem AND all other presenting problem AND all other systems (10 or more total) systems (10 or more total) Created by The Lung Doctor for e-Medtools 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 Document at least item from ANY of the areas Document at least 11item from ANY of the 33areas must be directly related to the problems identified in the HPI ItItmust be directly related to the problems identified in the HPI Complete All initial inpatient services require a Complete PFSH Document at least 1 item from EACH of the 3 areas Created by The Lung Doctor for e-Medtools The Exam Created by The Lung Doctor for e-Medtools Recognized Single Organ Systems Cardiovascular Ears, Nose, Mouth, Throat Detailed Detailed Eyes An extended exam of the affected body area An extended exam of the affected body area or organs/organ system and another Genitourinary (Female) or organs/organ system and another symptomatic or related area symptomatic or related 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 Created by The Lung Doctor for e-Medtools 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 *Refer to 1997 Guidelines for Evaluation & Management Services *Refer to 1997 Guidelines for Evaluation & Management Services Created by The Lung Doctor for e-Medtools Single 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 Created by The Lung Doctor for e-Medtools Elements of Individual Organ Systems Constitutional Vital signs General appearance of patient Nutrition, Body habitus, Development, Deformities, Grooming Cardiovascular Palpation of heart Auscultation Carotid artery exam Abdominal aorta exam Femoral arteries exam Pedal pulses exam Extremities for edema or varicosities 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 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 Services 1997 Guidelines for Evaluation && Management Services Neck Exam of neck Thyroid Respiratory Assessment of effort Percussion of chest Auscultation Palpation of chest Created by The Lung Doctor for e-Medtools Exam elements, continued Lymphatic Neck Axilla Groin Other Psychiatric Judgment and insight Orientation to person, time, place Memory, recent and remote Mood and affect 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 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 Services 1997 Guidelines for Evaluation && Management Services Skin Inspection Palpation Neurologic Cranial nerves Deep tendon reflexes Sensation Created by The Lung Doctor for e-Medtools Medical Decision Making Created by The Lung Doctor for e-Medtools Elements of Medical Decision Making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Complexity of Medical Decision Making Number of Diagnoses Or Management Options Minimal Limited Multiple Extensive Amount or Complexity of Data to be Reviewed Minimal or None Limited Moderate Extensive Risk of Complications Morbidity or Mortality Minimal Low Moderate High Complexity of Decision Making Straightforward Low Moderate High out of elements must be met 22out of 33elements must be met 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Worksheets Calculating Documentation Levels HGSAdministrators Documentation Worksheet HGSAdministrators Documentation Worksheet CMS Medicare Part CMS Medicare Part BB Adapted from Adapted from Created by The Lung Doctor for e-Medtools History HPI: Status of chronic conditions □ 1-2 □ 3 □1 condition □2 conditions □3 conditions HPI elements □Location □Severity □Timing □Modifying factors □Quality □Duration □Context □Associated signs & symptoms Review of Systems □Constitutional □ENT □GI □Skin, Breast □Endo/Lymph □Eyes □CV □MS □Neuro □Aller/Immun □Resp □Psych □All others negative PFSH □Past History □Family History □Social History Problem Focused □ Brief 1-3 □ Extended 4 or more □ None □ Pertinent to Problem 1 system □ Extended 2-9 Systems □ Complete 10 or more Systems □ None Expanded Problem Focused □ Pertinent 1 Detailed □ Complete 2 or 3 Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Examination Body Areas □Head, Face □Chest, Breasts, Axilla □Abdomen □Neck □Back, Spine □Genitalia, Groin, Buttocks □Each Extremity Organ Systems □Constitutional □ENT □Resp □MS □GI □Skin □GU □Psych □CV □Eyes □Heme/Lymph □Neuro Problem Focused Expanded Problem Focused □ 1 Body Area or System □ Up to 7 Body Areas or Systems □ Up to 7 Body Areas or Systems □ 8 or more Body Areas or Systems Detailed Comprehensive Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Medical Decision Making Reminder: There are 3 components used to determine the complexity of medical decision making • Number of diagnoses or Management Options • Amount or Complexity of data to be reviewed • Risk of Complications, Morbidity or Mortality Created by The Lung Doctor for e-Medtools Number of Diagnoses or Treatment Options Complexity of Medical Decision Making A Problem status Self-limited or minor Established problem (to examiner) Stable or improved B Number Max = 2 x C Points = D Result 1 1 2 Established problem (to examiner) Worsening New problem (to examiner) No additional workup planned Max = 1 3 4 New problem (to examiner) Additional workup planned Total Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Amount and/or Complexity of Data Reviewed Complexity of Medical Decision Making Reviewed Data Clinical lab tests reviewed and/or ordered Review and/or order of tests from radiology section of CPT Review and/or order of tests from medicine section of CPT Discussion of test results with performing physician Decision to obtain history from source other than patient Review and summarization of history obtained from source other than patient Independent visualization of image, tracing or specimen (NOT reviewing report) Points Result 1 1 1 1 1 2 2 TOTAL Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Guide to Determining Risk of Complications Complexity of Medical Decision Making Risk Minimal Presenting Problem -1 self-limited or minor problem Dx Procedure Ordered -Venipuncture -X-rays -EKG -EEG -Urinalysis -ECHO -Physiologic tests NOT under stress i.e., PFTs -Noncardiovascular imaging studies + contrast Barium enema -Superficial needle biopsies -Clinical lab tests requiring arterial puncture -Skin biopsies -Physiologic tests under stress Cardiac stress test Cardiopulmonary exercise test -Diagnostic endoscopies with NO risk factors -Deep needle or incisional biopsy -Cardiovascular imaging studies with contrast NO identifiable risk factors Cardiac catheterization -Obtaining body cavity fluid Thoracentesis -Cardiovascular imaging studies + Risk factors -Cardiac electro-physiologic tests -Diagnostic endoscopies + Risk factors -Discography Management Options Selected -Rest -Gargles -Elastic bandages Low -2 or more self-limited or minor problems -1 stable, well- controlled chronic illness -Acute uncomplicated illness or injury -OTC drugs -Minor surgery without identified risk factors -Physical therapy -Occupational therapy -IV fluids without additives Moderate -Mild exacerbation of 1 or more chronic illnesses -2 or more stable, chronic illnesses -Previously undiagnosed NEW problem with uncertain prognosis (i.e., breast lump) -Acute illness with systemic symptoms -Acute complicated injury -Minor surgery WITH identified risk factors -Elective major surgery with NO identified risk factors -Prescription drug management -Therapeutic nuclear medicine -IV fluids with additives -Closed treatment of fracture High -Severe exacerbation or progression of 1 or more chronic illnesses -Acute or chronic illness or injury that threatens life or limb -Abrupt change in neurologic status -Elective surgery + Risk factors -Emergency Major surgery -Parenteral controlled substances -Drug therapy requiring intensive monitoring -Decision to not resuscitate or to de-escalate care due to poor prognosis The highest level in ANY category determines the overall risk The highest level in ANY category determines the overall risk 1997 Guidelines for Evaluation Management Services 1997 Guidelines for Evaluation && Management Services Created by The Lung Doctor for e-Medtools Final Determination Complexity of Medical Decision Making A B C Number of diagnoses or treatment options Highest risk ≤1 Minimal Minimal 2 Limited Low 3 Multiple Moderate ≥4 Extensive High Amount and complexity of data reviewed ≤1 Minimal or Low 2 Limited Low Complexity 3 Multiple Moderate Complexity ≥4 Extensive High Complexity Type of decision making Straightforward Circle the appropriate descriptions for Rows A, B, C Circle the appropriate descriptions for Rows A, B, C The Column with or 3 circles determines the final Complexity of Medical Decision Making The Column with 22 or 3 circles determines the final Complexity of Medical Decision Making Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Determining Overall Service Levels Created by The Lung Doctor for e-Medtools Inpatient Encounters Initial Hospital Encounter Or Observation Requires 3 components within shaded area Subsequent Inpatient Or Follow up Requires 2 components History Examination Complexity of medical decision LEVEL Init Hosp Care Observation D or C D or C SF/L I 99221 99218 C C M II 99222 99219 C C H III 99223 99220 PF PF SF/L I 99231 99261 EPF EPF M II 99232 99262 D D H III 99233 99263 C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low C = Complete D = Detailed EPF = Extended problem focused H = High M = Moderate PF = Problem focused SF/L = Straight forward/Low Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Outpatient, Consults (Outpatient, Inpatient) and ER New Office / Consult / ER Requires 3 components within shaded area Established Office Requires 2 components History PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C Examination Complexity of medical decision LEVEL New Pt Outpt Consult Inpt Consult ER PF ER: PF EPF ER: EPF D ER: EPF C ER: D C ER: C SF ER: SF SF ER: L L ER: M M ER: M H ER: H Minimal problem that may not require presence of physician PF PF SF II -212 EPF EPF L III -213 D D M IV -214 C C H V -215 I 99-201 99-241 99-251 99-281 II -202 -242 -252 --282 III -203 -243 -253 -283 IV -204 -244 -254 -284 V -205 -245 -255 -285 I 99211 Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Documenting Time As a Determinant of Level of Service “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Time: Face to face in outpatient setting Unit/floor in inpatient setting □Yes □No □Yes □No □Yes □No Does documentation describe the content of counseling or coordinating care Does documentation reveal that more than half the time was counseling or coordinating care? Documentation of Time requires that ALL of the answers to the above questions are YES Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Adapted from CMS Medicare Part B HGSAdministrators Documentation Worksheet Created by The Lung Doctor for e-Medtools Summary Examples Documentation Requirements Created by The Lung Doctor for e-Medtools 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 Created by The Lung Doctor for e-Medtools 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 Created by The Lung Doctor for e-Medtools 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 Created by The Lung Doctor for e-Medtools 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 Created by The Lung Doctor for e-Medtools 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 Created by The Lung Doctor for e-Medtools We hope you found this presentation helpful! Remember to thank all the patient and knowledgeable billing and coding specialists who make themselves available to answer your questions in more detail! Created by The Lung Doctor for e-Medtools

October 28, 2008

Free E and M coding / audit tool

TheLungDoctor has shared a 2 page E&M coding/audit tool with us. This tool can help determine what level of E&M service has been provided, based on review of medical documentation.

This E&M coding/audit tool uses the method used by most Medicare carriers nationwide.

Health care providers working in Delaware, Maryland, Texas, Virginia, or the District of Columbia should use the method developed by
TrailblazerHealth (the Medicare carrier in the states mentioned above) to evaluate the Medical Decision Making portion of the E&M service.




Patient Facility DOB Encounter Date Chief Complaint is required in ALL documentation Criteria Status of 1-2 Chronic Conditions OR Brief 1-3 Elements Status of 1-2 Chronic Conditions OR Brief 1-3 Elements Pertinent to Problem MRN History Components HPI (History of Present Illness) Status of 3 chronic problems 1 2 3 Status of 3 Chronic Conditions Status of 3 Chronic Conditions OR Choose Elements Quality Location Duration Severity Timing Context Modifying factors Associated Signs/Symptoms ROS (Review of Systems) Constitutional ENT Eyes CV Skin/Breasts Resp Endo GI GU Heme/Lymph MS Neuro Psych Allergy/Immunology PFSH (Past Medical, Family Social History) Past History (Illnesses, Surgeries, Injuries) Past Family (Diseases, Hereditary illnesses) Social (Review of current, past activities) *Complete PFSH 3 history areas for ALL NEW Patients 2 history areas for ALL Follow Up/Established Visits OR Patients seen in Emergency Department OR Extended ≥4 Elements Extended (Pertinent to problem and other related systems) 2-9 Total OR Extended ≥4 Elements Complete (Pertinent and all related systems) NA 1 NA NA 10 Total Pertinent *Complete 1 Area PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED DETAILED 2-3 Areas COMPREHENSIVE ALL Criteria for selected level MUST be MET or EXCEEDED Examination Exam description Limited to affected body area or organ system Affected body area/organ system and other symptomatic or related organ systems Extended exam of affected body areas/organ systems and other symptomatic or related organ systems General Multi-System Complete Single Organ System 1995 Guideline 1997 Guideline Type of Exam 1 Body Area or Organ System 1-5 Bulleted Items PROBLEM FOCUSED EXPANDED PROBLEM FOCUSED 6-11 or more 2-7 12-17 or more for 2 or more systems 18 or more for 9 or more systems Refer to Guideline 2-7 ≥8 Not Defined DETAILED COMPREHENSIVE See 1995 or 1997 Guidelines for Evaluation & Management Services for specific requirements 1 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN A. Complexity of Medical Decision Making Number of Diagnoses or Treatment Options Problem (Status) Self-limited or minor (stable, improved or worsening) Est. problem (to examiner) stable, improved Est. problem (to examiner) worsening New problem (to examiner) no additional workup planned New problem (to examiner) additional workup planned Number Number Max = 2 x Max = 1 Circle corresponding answer on Line A of Final Result for Complexity Points = Points 1 1 2 3 4 Total Result Result B. Amount and/or Complexity of Data Reviewed Reviewed Data Review and/or Order of lab tests Review and/or Order of tests in the radiology section of CPT Review and/or Order of tests in the medicine section of CPT Discussion of test results with performing physician Decision to obtain old records and/or obtain history from someone other than the patient Review and summarization of old records and/or obtaining history from someone other than the patient and/or discussion of case with another health care provider Independent visualization of image, specimen or tracing (NOT simply review of report) Points 1 1 1 1 1 2 2 Circle corresponding answer Line B of Final Result for Complexity TOTAL C. Risk of Complications, Morbidity and/or Mortality Choose highest risk level and select corresponding risk level on line C in Final Result for Complexity Risk Min Low Mod Presenting problems 1 minor or self-limited 2 or more minor 1 stable chronic problem Acute uncomp illness/injury Mild exac  1 chron prob Dx procedures ordered Venipuncture, CXR, EKG, EEG Physiol tests NOT under stress Non CV imaging with contrast Superficial needle biopsies Physiologic tests under stress Dx endoscopies NO risk factors Deep needle or incisional bx CV imaging + contrast Obtain fluid from body cavity CV imaging + contrast, risk factors Card electrophysiologic studies Dx endoscopies + risk factors Discography Management options Rest, elastic bandages OTC drugs, PT, OT IV fluids without additives Minor surgery NO risk factors Minor surgery + risk factors Elective major surgery Prescription drug therapy Therapeutic nuclear medicine IV fluids + additives Elective maj surg + risk factors Emergency major surgery Parenteral controlled sub Rx requiring intense monitoring DNR or de-escalation of care 2 stable chron prob Acute illness + systemic Sx Acute complicated injury High Sev exac, 1 chron prob Acute or chronic illness posing threat to life/limb Abrupt change neuro status Final Result for Complexity of Medical Decision Making The column with 2 or 3 circles determines overall complexity of Medical Decision Making A B C Number Tx Options Amount of Data Highest Risk Decision Making Level 1 or less Minimal 1 or less Minimal Minimal 2 Limited 2 Limited Low 3 Multiple 3 Multiple Moderate 4 Extensive 4 Extensive High SF 2 Low Moderate High FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates Patient Facility DOB Encounter Date MRN OVERALL OUTPATIENT ENCOUNTER LEVEL New Office / Consult / ER History Exam Complexity Medical Decision LEVEL Requires 3 components within shaded area PF EPF D C ER: PF ER: EPF ER: EPF ER: D PF EPF D C ER: P ER: EPF ER: EPF ER: D SF SF L M ER: SF ER: L ER: M ER: M C ER: C C ER: C H ER: H Established Office Requires 2 components within shaded area Minimal PF EPF D problem that may PF EPF D not require SF L M presence of physician C C H I II III IV V I II III IV V PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity OVERALL INPATIENT ENCOUNTER LEVEL History Exam Complexity Medical Decision LEVEL Initial Hosp Encounter or Observation D or C C C D or C C C SF / L M H I II III Subsequent Inpatient or Follow Up PF EPF D PF EPF D SF / L M H I II III PF = Prob focused EPF = Expanded prob focused D = Detailed C = Comprehensive SF = Straightforward L = Low complexity M = Moderate complexity H = High complexity Time If ALL responses regarding time are “Yes”, billing may be based on Time “If the physician documents total time and suggests that counseling or coordinating care dominates (more than 50%) the encounter, time may determine level of service. Documentation may refer to: prognosis, differential diagnosis, risks, benefits of treatment, instructions, compliance, risk reduction or discussion with another health care provider.” Does documentation reveal total time? Must be face-to-face (Outpatient or Inpatient) Does documentation discuss the content of counseling or coordination of care? Does documentation reveal that more than half the time was spent on counseling or coordination of care? Yes Yes Yes No No No References 1997 Guidelines for Evaluation and Management Services http://www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdf HGSAdministrators Documentation Worksheet www.aace.com/advocacy/pdf/AUDITTOOLMEDICARE.pdf Evaluation and Management Coding and Documentation Reference Guide Trailblazer Health Enterprises, LLC 3 FREE Medical Documentation Tool brought to you by The Folks at MedicalTemplates

October 23, 2008

MedSpel 7.60 Released

MedSpel, our award winning medical spelling tool for Microsoft Word, has been updated with an improved installer, new drug names, and new medical device names.

Drug and device names are current with FDA approvals through October 13, 2008.

MedSpel has been continually updated since 1998, and costs costs $19.95 for a single user and only $1,000 for unlimited users.

Get it from CNET Download.com!Buy MedSpel now from Regnow.com

Screen Shot of MedSpel medical spelling dictionary in use.

October 22, 2008

MedSpel vs The Competition

MedSpel has been continually updated since 1998, and is the most affordable medical speller for Microsoft Word on the market. Here is how MedSpel stacks up to the competition -


MedSpel Spellex
Medical &
Pharmaceutical
Sylvan's Medical Pharmaceutical Spell Check Inductel Medical Speller
Last Updated 2008 (v7.6) 2008 2007
(v2.3)
2007
Cost/User $19.95 $159 $89.97 $29.95
Cost/5 Users $40 $415.14 $345.97 $49.90
Cost/10 Users $80 $775.14 $549.97 $87.30
Cost/100 Users $400 $3,756 Call for price $499
Upgrade cost per user FREE $49.95 $36.97 $14.95



October 14, 2008

APACHE II calculator for Google Desktop

e-MedTools has released a new APACHE II calculator for Google Desktop.

This ICU severity of illness calculator that uses the APACHE II (Acute Physiology and Chronic Health Evaluation II) method outlined by Knaus et al. in 1985.

This scoring system has been validated in many subsequent clinical trials, and remains commonly used ICU severity of illness estimation. Scores calculated by the APACHE II method range from 0 to 71. Higher scores indicate greater severity of illness, and an increased risk of death.



June 4, 2008

Pneumonia Severity Index Google Gadget

The pneumonia severity index (PSI) Google Gadget helps assess the severity of pneumonia with a well established and validated tool. The PSI has been used to determine which patients can be treated safely as outpatients, and identify those with the highest risk of death due to pneumonia.

You can learn more about the Pneumonia Severity Index here.>

Free pneumonia severity index Gadget



May 22, 2008

Creatinine Clearance Google Desktop Gadget

The Creatinine Clearance Gadget estimates renal function with the Cockcroft-Gault equation. Knowledge of creatinine clearance is important for the assessment of renal dysfunction and proper dosing of medications that are eliminated by the kidneys.

You can learn more about the Cockcroft-Gault equation here.>
Free creatinine clearance Gadget



May 14, 2008

GenericMedList Google Desktop Gadget

The new GenericMedList Google Desktop Gadget has been released.

The GenericMedList Google Desktop Gadget is a mini-application that can be placed anywhere on your computer desktop or in a sidebar organizer to allow searches of GenericMedList.com.


The GenericMedList Desktop Gadget uses a custom search engine powered by Google to provide search results.
The GenerciMedList Google Desktop Gadget requires the free Google Desktop, and will run on Windows and MacOS computers. Google Desktop is a component of the Google Pack.


May 13, 2008

Medicare Reference Google Desktop Gadget

The free Medicare Reference Google Desktop Gadget provides direct access to the Medicare physician fee schedule, PQRI (Physician Quality Reporting Initiative) criteria and worksheets from the American Medical Association, and the 1997 Documentation Guidelines for Evaluation and Management Services. These three key resources are useful to any medical practice that bills Medicare.

The Medicare Reference Google Desktop Gadget is a mini-application that can be placed anywhere on your computer desktop or in a sidebar organizer to provide ready access to important Medicare information.

The Medicare Reference Google Desktop Gadget requires the free Google Desktop, and will run on Windows and MacOS computers. Google Desktop is a component of the Google Pack.

April 16, 2008

GenericMedList Search Widget

Our new GenericMedList Search widget is now available for Facebook, Blogger, Wordpress, iGoogle, NetVibes, and many other services.

This widget adds GenericMedList search to nearly any web page.


April 3, 2008

Wegmans $11.99 drugs added to GenericMedList

GenericMedList now includes the Wegmans $11.99 for 90 days generic drug discount program.

Wegmans
operates stores in New York, Pennsylvania, New Jersey, Virginia, and Maryland.

The Wegmans discounted medication list can be downloaded from here.

March 11, 2008

New Problem Specific MedicalTemplate Bundle

The new MedicalTemplate bundles have been expanded to include the Problem Specific Bundle. The Problem Specific Bundle includes 6 MedicalTemplates at a 25% discount.

MedicalTemplates in the Problem Specific Bundle -


Save 25% and Buy pulmonary disease bundle now from REGNOW.COM

New Hypertension Management MedicalTemplate

A new hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected hypertension (high blood pressure) was released today.

The Hypertension management MedicalTemplate includes reminders for the JNC7 hypertension management goals.




Read this document on Scribd: Hypertension Follow up Evaluation

Hypertension Evaluation Date Start Time Stop time Patient Name Patient DOB MRN Chief complaint/Reason for consult History of Present Illness Referring MD Data Reviewed ‰Allergy list ‰Medication list ‰Past Medical History ‰Past Surgical History ‰Social History ‰Family Medical History ‰Patient’s Blood Pressure log ‰Recent labs and diagnostic tests Review of Systems ‰Premature Coronary Artery Disease ‰Hyperlipidemia ‰Cardiac disease ‰Congenital Adrenal Hyperplasia ‰Diabetes ‰Dyslipidemia ‰Renal disease ‰Polycystic Ovarian Syndrome ‰Sleep Apnea ‰Renal artery stenosis Pulse Sitting RR Standing ‰Thyroid disease ‰BMI t  ‰Smoking ‰Physical inactivity Physical Exam Vitals Ht Wt BMI BP L arm R arm General ‰ Alert Eyes ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro Psych Supine ‰ = Patient denies problems ‰Constitutional ‰Eyes ‰Vision changes ‰Pain ‰Weight changes ‰Fatigue ‰Fever ‰ENT/mouth ‰Resp ‰CV ‰GI ‰Ulcers ‰Tooth pain ‰Nose bleeds ‰Dyspnea ‰Cough ‰Sputum ‰Chest pain ‰Exercise intolerance ‰Diaphoresis ‰Paroxysmal nocturnal dyspnea ‰Nausea ‰Vomiting ‰Diarrhea ‰ Abdominal pain after eating ‰Dysuria ‰Polyuria ‰Erectile dysfunction ‰Myalgias ‰Bony pain ‰Claudication ‰Sores, ulcers ‰Dry, cracked skin ‰Numbness ‰Paresthesias ‰Focal weakness ‰Hypoglycemia ‰Tremors ‰GU Additional Findings ‰Conjunctivae ‰Pupils ‰Discs ‰No visible retinal pathology ‰Nasal mucosa ‰Dentition ‰Oropharynx ‰Normal to palpation ‰Thyroid ‰No JVD ‰Clear to auscultation ‰Clear to percussion ‰Effort ‰Normal to palpation ‰Auscultation ‰Palpation ‰Edema ‰Carotids ‰Aorta ‰Femoral pulses ‰Pedal pulses ‰No palpable masses ‰Liver and spleen not palpable ‰No hepatojugular reflux ‰No lymphadenopathy ‰Enlarged lymph nodes palpable ‰Neck ‰Axilla ‰Groin ‰Other ‰Gait ‰Digit ‰Inspection ‰ROM ‰Stability ‰Strength ‰No clubbing ‰No cyanosis ‰No sores ‰Inspection ‰Palpation ‰Oriented ‰CN ‰DTR ‰Sensation intact ‰Vibratory sense intact ‰Affect ‰Orientation ‰Insight ‰Memory ‰Musc ‰Skin/breasts ‰Neuro ‰Endo Impression & Plan Blood Pressure Class ‰Normal ‰Prehypertension ‰Stage 1 ‰Stage 2 SBP <120 120-139 140-159 t160 DBP <80 80-89 90-99 t100 ‰Patient at goal < 140/90 or <130/80 for DM ‰Not at Goal ‰Heme/lymph ‰Allergy/Immun ‰Psych ‰Easy bruising ‰Swollen lymph nodes ‰Sinus pain ‰Nasal discharge ‰Depression ‰Anxiety ‰Hallucinations Follow up ‰This clinic ‰Endocrinology ‰Nephrology ‰Ophthalmology ‰Other Signature cc Estimated Creatinine Clearance * Multiply by 0.85 for females Normal Creatinine Clearance in healthy young females ~100mL/min/1.73m2 Normal Creatinine Clearance in healthy young males ~120mL/min/1.73 m2 (140 – age) x weight (in kg) = Plasma Creatinine x 72 Labs Therapy ‰Urinalysis ‰CBC ‰PT, PTT, INR ‰BMP ‰LFTs ‰Triglyceride level ‰LDL and HDL ‰BNP ‰EKG ‰ECHO ‰TSH ‰Aspirin ‰ACE-I or ARB ‰Beta blocker ‰Calcium Channel Blocker ‰Thiazide diuretic ‰Loop diuretic ‰Statin ‰Other ©MB and RR 2006-2008 Revised 10March08 e-medtools.com



JNC 7 Guidelines

The hypertension evaluation MedicalTemplate includes the hypertension staging system and reminders for the suggested laboratory workup outlined in the JNC 7 report. The JNC 7 is the The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure of the National Heart, Lung, and Blood institute.

JNC 7 Full Guidelines
JNC 7 Pocket Reference