January 3, 2010

Trailblazer Medicare Audit Tool

The Trailblazer Medicare Audit Tool is designed for use by health care providers and their staff. Health care providers, even those in training, can use the Trailblazer Medicare Audit Tool to determine appropriate billing levels for the complexity of medical documentation for each patient encounter. It can also be helpful for learning the complexities of medical documentation, and for assisting internal audits for EM documentation. The Trailblazer Medicare Audit Tool is created in a fillable PDF format, permitting users to rapidly complete the form digitally on any computer, but can still be printed out and manually completed.

Each Trailblazer Medicare Audit Tool has readily visible and easy to use check boxes and fillable text boxes for marking the appropriate level of documentation for the medical History, Exam and Medical Decision Making.

The Trailblazer Medicare Audit Tool is subdivided into the following categories:
History
Exam
Medical Decision Making

The History is subdivided into the following categories:
History of Present Illness (HPI)
Review of Systems (ROS)
Past Medical, Family and Social History (PFSH)

Medical Decision Making is further subdivided into 3 categories:
Number of Diagnoses OR Number of Treatment Options
Data Reviewed or Ordered
Risk of Complications, Morbidity or Mortality

The sum of the 3 categories of Medical Decision Making determine the Complexity of Medical Decision Making.

The levels of the History, Exam and Complexity of Medical Decision Making determine the Overall Patient Encounter Level.

Trailblazer Medicare Audit Tool

No comments: