e-MedTools News

iBookstore Release featuring Code Check Pro

2011-12-07T08:00:00.000-06:00

A new release in the iBookstore features Code Check Pro. Check out the free iBook!

OpenMedSpel updated for Firefox

2011-12-06T07:00:00.000-06:00

OpenMedSpel has been updated for all Mozilla FireFox versions through version 10!

Add this free world class medical spelling tool to your browser.

Click here to get OpenMedSpel from Addons.Mozilla.org

Code Check Pro featured in a Google Book

2011-12-05T21:55:00.001-06:00

Code Check Pro featured in Kindle Book

2011-11-19T21:53:00.001-06:00

Code Check Pro and other E&M coding apps for iOS are featured in a new Kindle Book called "Medical Coding Apps for the iPhone and iPad"

Best iPhone apps at AppStoreHQ

Code Check featured in Fall iOS Apps for Hospitalists

2011-11-03T15:22:00.002-05:00

Medical Apps for Hospitalists on the iPhone and iPad - Fall 2011
Best iPhone apps at AppStoreHQ

iRVU is in the Amazon Appstore for Android

2011-03-24T17:47:00.000-05:00

iRVU: Hospital has been accepted in the new Amazon Appstore for Android phones and tablets. We hope this new distribution portal will dramatically expand the user base of our free medical productivity tracking app among Android users.

Pneumonia Evaluation MedicalTemplate Updated!

2011-02-26T14:54:00.000-06:00

e-MedTools has update the Pneumonia Evaluation MedicalTemplate!

The newly revised template has the popular ROS with "Yes" and "No" options. The Exam section is expanded, with prompters for documenting noninvasive ventilator settings for CPAP and BiPAP. There are also prompters for invasive ventilator settings.

The Impression and Plan section has prompters for documenting the complexity of Medical Decision Making.

A brand new feature is a Pneumonia Severity Index score! This PSI score totals the score as you choose the individual options from each drop box!

Physicians now supervising medical students, residents, nurse practitioners and physician assistants will love the newly expanded Impression and Plan section with room for two separate notes.

Interstitial Lung Disease MedicalTemplate Updated

2011-02-24T17:27:00.000-06:00

e-MedTools has updated the Interstitial Lung Disease MedicalTemplate!

Updated features include the popular Review of Systems with "Yes" and "No" options. The History of Present Illness includes prompters for pertinent criteria for diagnosing interstitial lung disease along with an occupational and exposure history.

The Past Medical, Family and Social History has been streamlined.

The Exam contains prompters for non-invasive and invasive ventilator settings.

The Impression and Plan contains separate spaces for supervising physicians and physician extenders - a perfect option for physicians supervising residents, nurse practitioners and physician assistants!

Updated Lung Mass Evaluation MedicalTemplate

2011-02-24T17:19:00.001-06:00

e-MedTools has updated the Lung Mass Evaluation MedicalTemplate!

The new and improved Lung Mass Evaluation MedicalTemplate has the very popular Review of Systems with "Yes" and "No" options. It also includes updated prompters in the History of Present Illness.

The Exam section contains space for documenting invasive or non-invasive ventilator settings, and more space for "Additional Findings" - perfect for the physician who supervises residents, nurse practitioners or physician assistants!

The Impression and Plan section contains separate text boxes for physicians and physician extenders.

E/M Code Check Updated

2011-02-20T20:19:00.001-06:00

E/M Code Check is now updated to include Trailblazer's rules for Medicare patient encounter documentation.
E/M Code Check is the ONLY smart phone app to incorporate the Trailblazer requirements for E/M encounters!
Best iPhone apps at AppStoreHQ

DRG Modifier Tool

2011-02-17T19:24:00.003-06:00

e-Medtools is providing, as a public service, a free abbreviated list of DRG Modifiers that qualify as Major Complications and Comorbid Conditions (MCC) & Complications and Comorbid Conditions(CC) as defined by the Centers for Medicare & Medicaid (CMS).

These MCCs and CCs are important to every healthcare provider because they help hospitals maximize reimbursement in accordance with the appropriate level of severity of illness for a given patient. Every healthcare provider deserves to be paid appropriately for services provided. Healthcare is a team effort, and every member of the healthcare team owes it to themselves, their colleagues and their patients to work together for mutual benefit.

At a time when Medicare continues to decrease reimbursement to all healthcare providers, it is more important than ever to work diligently to educate ourselves on navigating an increasingly complex reimbursement system. Hospitals play a important role in every community. Hospitals routinely provide free access to healthcare without regard to ability to pay for services rendered. Hospitals are often major employers in communities, and are often integral to community support efforts. It is therefor critical to support hospitals by every possible means to ensure that they can receive payment appropriate for the level of care provided.

One important note: MCCs and CCs use terminology specific to the CMS, and MUST be documented by a healthcare practitioner, preferentially in the Discharge Summary.

Medicare regulations prohibit Hospitals from providing this information to healthcare providers. Please consider reviewing this form, print as many copies as you like, and check all that apply and include this information in your patient documentation.

We hope that you find this information helpful, and we look forward to your feedback.

Sincerely,
The Folks at e-MedTools, creators of MedicalTemplates, MedSpel, E/M Code Check and iRVU

Updated Sepsis MedicalTemplate

2011-02-13T07:07:00.000-06:00

e-MedTools has updated the popular Sepsis Evaluation MedicalTemplate.

The History of Present Illness (HPI) has been revised to limit prompters to risk factors for infection. The Review of Systems (ROS) has been revised to the expanded format that contains "Yes" and "No" options. The Exam portion still contains room for documenting important data such as Ventilator Settings, Lines & Monitors, IV Medications, Labs and Radiographs.

The newest feature added to a select few MedicalTemplates includes documentation space for physicians supervising residents, nurse practitioners and physician assistants. This is great for academic physician practices, or those practices utilizing physician extenders.

Every MedicalTemplate contains easy to use checkboxes and fillable textboxes to streamline the patient encounter and medical documentation process.

Updated Clinic History and Physical Exam MedicalTemplate

2011-02-13T06:55:00.000-06:00

e-MedTools has updated the Clinic History and Physical Exam MedicalTemplate.

The Review of Systems is expanded in the easy to use format that permits "Yes" and "No" options, important for documenting pertinent positive and negative findings. The Exam portion now includes prompters for documenting CPAP and BiPAP settings for patients using noninvasive ventilators for obstructive sleep apnea or pulmonary artery hypertension.

The Clinic History and Physical Exam MedicalTemplate now comes in two versions! One version is for physicians working independently. Another version is designed for physicians supervising residents or physician extenders, such as nurse practitioners and physician assistants.

Every MedicalTemplate contains easy to use checkboxes and fillable textboxes that help physicians streamline their patient encounter and medical documentation times.

New Orthopedic MedicalTemplate Released

2011-02-13T06:38:00.000-06:00

e-MedTools is happy to announce the release of a brand new MedicalTemplate - Orthopedic Evaluation.

The Orthopedic Evaluation includes a list of commonly asked questions as prompters in the History of Present Illness (HPI); an easy to use Review of Systems; and a detailed single organ system exam. New to MedicalTemplates is room for Supervising Physician notes - great for physicians who work with residents or physician extenders!

Every MedicalTemplate has easy to use check boxes and fillable textboxes. This helps busy physicians streamline patient encounters and the complex documentation process necessary for reimbursement.

iRVU overview presentation

2010-10-26T21:19:00.000-05:00

iRVU Overview

iRVU - New iPhone Medical Productivity App

2010-10-20T14:38:00.002-05:00

e-MedTools released a new iPhone medical productivity app in the iTunes App store - iRVU!

iRVU lets you track work RVUs (Relative Value Units) for inpatient medical services like new patient H&Ps, critical care visits, consults, and follow up visits at the point of care.

A work RVU log is important for inpatient physicians such as hospitalists and intensivists because income is usually linked to work RVU production.

iRVU lets you keep a running tab on your RVUs so you can estimate your productivity based pay whenever you need to.

iRVU also includes business intelligence functions like reporting RVUs per encounter and charges per encounter. These ratios can be compared to the other members of your practice or a set of benchmark data like MGMA survey data.

10 Reasons To Own E/M Code Check

2010-10-12T13:46:00.001-05:00

e-MedTools is proud to announce the release of its newest product, E/M Code Check.

E/M Code Check is a smartphone application for medical documentation and coding. It features the Medicare documentation requirements for multiple patient encounter coding levels, Medicare allowable charges, and Medicare work RVUs (Relative Value Units) for each encounter code.

E/M Code Check also has exciting unique features not found in other smartphone applications, like Medicare coding distribution graphs and a Personal Productivity Log.

The Personal Productivity Log tallies the information for each patient encounter (total number of patient encounters, coding levels, wRVUs, Medicare allowable charges) and graphs it in a succinct, easy to read format. The graphic information even separates inpatient data from outpatient data.

This is a vital tool for physicians and other health care providers.

10 Reasons to Own EM Code Check
Best iPhone apps at AppStoreHQ

Medical Smartphone App Survey

2010-10-08T19:08:00.001-05:00

Presentation - E/M Code Check Basic

2010-09-08T12:23:00.000-05:00

E/M Code Check Basic Overview
Best iPhone apps at AppStoreHQ

E/M Code Check now on Android Phones

2010-08-19T21:17:00.000-05:00

E/M Code Check, our physician designed medical coding tool, is now available as a free application for Android Smartphones such as the Droid 2.

What is a QR-Code?

Documentation requirements are presented in a clear, concise format. In just 3 easy steps you can find all the information you need to document a patient encounter!

iPhone Medical Coding App Released

2010-08-12T21:54:00.001-05:00

Our new medical coding app for the iPhone and iPod Touch is now in the AppStore!

E/M Code Check is a physician created evaluation and management coding application that presents complex medical documentation requirements in a clear and concise format.

Documentation requirements, Medicare RVUs, Medicare reimbursement rates, and medicare coding distributions for 10 specialties are included in this app.

E/M Code Check can help you review your medical documentation for compliance in just 3 screen taps - a real time saver!

Features unique to E/M Code Check

Average Medicare Reimbursement Rates
Medicare Coding Level Distribution
Personalized Productivity Log

A personalized productivity log provides you unique insight into your coding habits.

E/M Code Check costs $34.99 and is available in the iTunes AppStore.

Best iPhone apps at AppStoreHQ

MedicalTemplates and Medicare

2010-03-01T21:37:00.001-06:00

Now more than ever, MedicalTemplates can help maximize reimbursement from Medicare. This is especially true for subspecialists who, since January 1, 2010, had up to an 11% reduction in Medicare reimbursement. This is now magnified with a 21% decrease in reimbursement for all physicians.

MedicalTemplates have quick, easy to use prompters with check boxes and fillable text boxes that are based on the 1997 Guidelines for Evaluation and Management Services.

Thorough documentation, if done by hand, could take 20-30 minutes to write. Using MedicalTemplates takes just 5-10 minutes to complete. Saving just 10 minutes per patient could save 2 or more hours every day!

Thorough medical documentation is only half the battle, of course. Appropriate coding is also important, and MedicalTemplates provides free Medicare Audit Tool worksheets to assist with determining patient encounter levels.

New Pulmonary Clinic Outpatient Evaluation

2010-02-04T08:50:00.002-06:00

MedicalTemplates have updated their outpatient pulmonary evaluation template "Pulmonary Clinic New Outpatient Evaluation"!

The new Outpatient Pulmonary Evaluation template has time-saving updates which you are sure to like!

The new template has a streamlined Past Medical History that includes an Occupational History and Military History section, a revamped Review of Systems with "yes" and "no" options, a detailed exam with pertinent positive and negative findings, and an expanded Impression with diagnostic plan prompters.

The newest addition is a lung diagram for graphically documenting a 2-dimensional position of abnormalities noted radiographically. This can be a quick reminder for future office visits.

All MedicalTemplates have easy to use check boxes and fillable textboxes for fast, efficient and thorough medical documentation!

Also included in the "Pulmonary Clinic New Outpatient Evaluation" are help buttons relating to documentation requirements, based on the 1997 Guidelines for Evaluation and Management Services.

Consistent documentation that is thorough and concise is cost-effective, medically and legally beneficial, and a great time saver!

Pulmonary Clinic History and Physical

Clinic H&P Updates

2010-01-21T18:44:00.005-06:00

The Clinic H&P MedicalTemplate for outpatient evaluations has undergone major updates and is now available!

The new, updated Clinic H&P now has helpful hints for assisting with documentation necessary for proper billing and coding, based on the 1997 Guidelines for Evaluation and Management Services. The Review of Systems has been updated to reflect "yes" and "no" options. The History of Present Illness has been expanded to permit more writing space. The Past History has been streamlined. The exam has been expanded to include pertinent positive and negative findings. The Impression and Plan section contains additional writing space, and has space for documenting code status and diagnostic plans.

We are confident that these updates will make patient encounter documentation easier and more likely to result in better coordination of documentation and coding!

Clinic History and Physical MedicalTemplate

New Inpatient Evaluation Template

2010-01-14T08:39:00.005-06:00

The New Inpatient Evaluation template designed for the initial evaluation of hospital patients is now updated.

The most important change to the New Inpatient Evaluation template is that it has been modified to reflect the format and wording described in CMS' 1997 Guidelines for Evaluation & Management Services. Help buttons in major sections describe information regarding the documentation necessary for coding.

Other important upgraded features include:
1. Expanded Review of Systems with more signs and symptoms AND yes/no options
2. Streamlined Past Medical History
3. Expanded Exam with check boxes for pertinent positive and negative findings
4. Code status
5. 3 page format with expanded Impression and Plan

Like all MedicalTemplates, the New Inpatient Evaluation template is in Adobe Acrobat PDF format that contains active check boxes and fillable text boxes. The PDF format makes medical documentation with MedicalTemplates simple, efficient, and reliable. The PDF format makes it easy to carry information to any location, save data for later reference, and make changes as needed.

New Inpatient Evaluation (History and Physical)

COPD Evaluation Template for Outpatients

2010-01-08T12:33:00.003-06:00

MedicalTemplates has released a new COPD (Chronic Obstructive Pulmonary Disease) Evaluation Template designed for use by all health care providers in the outpatient setting. The template is in a fillable PDF format by Adobe Acrobat and contains checkboxes and fillable textboxes.

The new COPD Evaluation Template has generous space for documenting the HPI, and contains prompters that readily distinguish the severity of illness and recent symptoms or events that may indicate a need for changes in the COPD medication regimen, or even hospitalization.

The Review of Systems has convenient buttons for checking "yes" or "no" options, dramatically reducing the time spent on this task.

The Past Medical, Family and Social History (PFSH) contains disease-specific prompters for common or relevant disorders. In addition, there are prompters for a detailed Malignancy history, occupational or inhalational exposure history, and common diseases among family members that may affect a patient's health.

The Exam emphasizes pertinent positive and negative exam findings, and contains space for free text documentation of additional findings.

The Impression and Plan is generously sized to permit detailed discussions, and contains convenient prompters for common treatments, diagnostics and lab tests.

Prompters with simple check boxes limit the need for handwriting or typing. Fillable text boxes permit free text descriptions for areas that require further, detailed documentation. Features such as these help to improve health care provider efficiency by decreasing the time needed to document a patient encounter, ensure that essential topics are discussed, improve documentation, and provide supporting documentation for adequate billing and coding needs. The COPD Evaluation Template was created following the Centers for Medicare & Medicaid Services' (CMS) 1997 E & M Documentation Guidelines, and the development team included a board-certified Pulmonary Disease Specialist.

The COPD Evaluation Template for outpatients is a valuable tool for all health care providers who evaluate and treat patients with COPD, or those at risk of developing COPD. The COPD Evaluation Template helps to make documentation as fast and easy as possible.

Outpatient evaluation for COPD Medical Documentation Template

e-MedTools Is Now On Twitter

2010-01-04T10:48:00.002-06:00

Tweeting is our latest venture. Check out updates on e-MedTools, MedSpel and MedicalTemplates on our Twitter page.

We look forward to hearing from you!

Psychiatry Evaluation Template Updated!

2010-01-04T10:28:00.005-06:00

Good Monday Morning!

MedicalTemplates has just released an updated version of the Psychiatry Evaluation Template. This version is far superior to the previous version!

The new Psychiatry Evaluation Template has increased the size of the HPI box for free text. The Review of Systems (ROS) has been expanded to include Yes/No options. The Past Psychiatric History (in the PFSH) has been expanded to include hospitalizations and treatments. The Exam portion is more detailed and contains expanded free text boxes, and the Impression section has been expanded to include prompters for Data Reviewed, Care Coordinated With, Recommended Diagnostics and Recommended Actions.

We think folks are going to love the improvements, and we value any and all feedback!

Thank you to all those who have already purchased a Psychiatry Evaluation Template! Look in your e-mail for your complementary updated MedicalTemplate!

Be sure to check us out on Twitter for more frequent updates:)

Trailblazer Medicare Audit Tool

2010-01-03T20:55:00.008-06:00

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

New Influenza Like Illness MedicalTemplate for Flu Season 2009-10

2009-10-29T17:08:00.007-05:00

The creators of MedicalTemplates have a new template designed specifically for the evaluation of patients with Influenza Like Illness (ILI).

The 2009-2010 influenza season has been marked by rapid spread of a novel H1N1 Influenza A virus (often referred to as “Swine Flu”). Identified in April 2009, H1N1 has been identified worldwide and is widespread in virtually every state in the United States as of the week ending October 17, 2009, according to the Centers for Disease Control and Prevention. In response to the rapid spread of this H1N1 virus, President Obama declared a national emergency on October 24, 2009.

Unlike seasonal Influenza A, the novel H1N1 Influenza A virus has affected primarily people under the age of 65. While a monovalent vaccine free of adjuvants has been created, it is not yet widely available. Groups targeted to receive the H1N1 Influenza A vaccine are

1. Pregnant women

2. People who live with or work with infants less than 6 months of age

3. Health care and emergency service personnel

4. Children and young adults ages 6 months-24 years

5. Adults aged 25-64 years with medical conditions that predispose them to influenza-related complications

The unseasonably early and rapid spread of influenza has resulted in an 8-fold increase in the number of outpatient clinic visits for Influenza Like Illness, further straining health care resources. By week 40 of 2009, 8% of all outpatient visits were due to Influenza Like Illness, compared to 1% in years 2006-2008 during the same period (CDC).

The Influenza Like Illness evaluation template can be used in either the outpatient or the inpatient setting by any health care provider.

The Influenza Like Illness evaluation template can be used for the evaluation of Influenza Like Illness from any cause, including seasonal influenza, novel H1N1 influenza, pneumonia from any cause, etc.

Prompters in the History of Present Illness (HPI) section assist health care providers in rapidly evaluating symptoms and risk factors for influenza, and permit ready documentation of recent vaccinations. The Past Medical, Social and Family History (PMSF) section has been streamlined to permit documentation of the most frequent chronic medical problems, functional status, risk factors and family history. The Exam section of the Influenza Like Illness evaluation template contains prompters for both pertinent positive and negative exam findings, and more space has been allocated for additional exam findings. The Impression and Plan section now has more space for documentation, and contains prompters for documentation of “code” status and Health Care Power of Attorney discussions.

The Influenza Like Illness evaluation template, with its easy to use checkboxes and fillable textboxes, makes complete and thorough medical documentation faster and easier than ever before! Faster, easier documentation is important during every influenza season when all health care providers are at their busiest. The Influenza Like Illness evaluation template is vitally important this influenza season!

Influenza Like Illness Medical Documentation Template

OpenMedSpel for Mozilla approved

2009-10-24T19:54:00.003-05:00

OpenMedSpel, our free and open source medical spelling tool, is now an approved add on for Mozilla Firefox, Thunderbird, and SeaMonkey!

OpenMedSpel brings a world class medical spelling tool to the Mozilla family of internet applications.

OpenMedSpel for Mozilla can be downloaded from Addons.Mozilla.org

COPD documentation just got easier!

2009-10-06T19:48:00.003-05:00

MedicalTemplates has expanded and updated the COPD Evaluation template to include more of the information health care providers need to document.

Improvements include prompters for assessing COPD exacerbations and streamlining the Past Medical, Social and Family History. Other improvements include expanded exam findings suitable for either a general multipurpose exam or a single organ respiratory exam, space for ventilator settings, intravenous medications, and labs.

The Impression and Plan section is now expanded to an entire page to permit additional documentation for complex patient encounters.

MedicalTemplates’ new COPD documentation template decreases documentation time, increases health care provider efficiency, and effortlessly assists with improving encounter documentation.

Thank you to all the folks who field test MedicalTemplates and provide helpful feedback!

Chronic Obstructive Pulmonary Disease Evaluation

Comprehensive Medical Terms Add-On Reference for SpellCatcher Features OpenMedSpel

2009-06-04T07:37:00.003-05:00

Rainmaker Research Inc. has included OpenMedSpel in an add on dictionary for the award winning Spell Catcher line of medical spelling tools.

From Rainmaker Research Inc.

Courtesy of the folks at e-MedTools, we’ve created a Spell Catcher format Learned Words file that includes medical terminology from the MedSpel project. This reference contains over 35,000 medical terms not available in the U.S. English Medical Additional Spellings database. Use this file in conjunction with the standard U.S. English Medical Spellings for a grand total of nearly 60,000 medical terms!

Available for all Spell Catcher products, download the one you need from the appropriate Add-Ons page:

Spell Catcher X
Spell Catcher Plus
Spell Catcher 8

It’s also available on from the Downloads page for each product, and our Languages page.

And best of all, it’s free!

New Pulmonary MedicalTemplate Bundles

2009-05-28T20:47:00.002-05:00

The Folks at MedicalTemplates have created 3 new pulmonary MedicalTemplate bundles to meet the needs of any pulmonologist!

Common Pulmonary Problems Bundle
This MedicalTemplate bundle includes the COPD new patient, Sleep, Lung Mass, Asthma, Interstitial Lung Disease and Pulmonary Hypertension templates at a 25% discount. This MedicalTemplate bundle costs 675 + any required taxes for a single user. Click here to order the Common Pulmonary Problems Bundle.

Complete Pulmonary Problem-Specific Bundle
We are offering a 10 template bundle at a 30% discount! That is a $1500 value for just $1050! Templates included in this bundle are Sepsis, Pneumonia, Asthma, COPD New Eval, COPD Follow Up, Pleural Effusion, Pulmonary Artery Hypertension, Interstitial Lung Disease, Lung Mass, and Sleep Disorder Evaluation. To save 30% on a 10 template bundle, click here.

The Everything Pulmonary Bundle
Save 35% on the purchase of 13 pulmonary MedicalTemplates!
A $1950 value for just $1275! That is like getting 4 1/2 templates for free!
Templates included are Pulmonary clinic H&P, Pulmonary Hospital H&P, Pulmonary Hospital Follow Up, Sepsis, Pneumonia, Asthma, COPD New Eval, COPD Follow Up, Pleural Effusion, Pulmonary Artery Hypertension, Interstitial Lung Disease, Lung Mass, and Sleep Disorder Evaluation.

To save 35% on a 13 template bundle, click here!

Dierbergs, Giant Food, and Giant Eagle added to GenericMedList

2009-01-30T13:57:00.002-06:00

The GenericMedList database has been expanded to include generic discount programs at Dierbergs, Giant Food, and Giant Eagle pharmacies.

GenericMedList is a free searchable database of generic medication discount programs similar to the well known Walmart $4 per month medication program.

GenericMedList features the following generic medication discount programs

Walmart | Target | KMart | Kroger | Meijer | Schnucks | Publix | Wegmans | Giant Eagle | Dierbergs | Giant Food

COPD Evaluation Medical Template Revised

2008-12-15T07:45:00.000-06:00

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

Publish at Scribd or explore others: Nursing and Health P Medical maintenance exercise inspiratory muscle t

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

OpenMedSpel for OpenOffice.org 3.0

2008-12-08T11:01:00.003-06:00

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.

Medical Decision Making Calculator - Google Desktop

2008-11-10T20:25:00.005-06:00

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.

Pulmonary Hospital H&P or Consult Note Updated

2008-11-02T07:59:00.006-06:00

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.

Respiratory Single System Exam OR General Multisystem Exam
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

Follow this link for a concise review of the medical documentation requirements for E&M services.

Pulmonary / Critical Care New Patient Evaluation

Get your own at Scribd or explore others: Health Medical Medical Religion

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

E & M Coding/Audit Worksheet in Aqua/Grey

2008-10-30T07:53:00.003-05:00

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.

E and M Documentation and Coding Worksheet in Aqua and Gray - Upload a Document to Scribd

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

Demystifying Medical Documentation

2008-10-29T08:31:00.000-05:00

Demystifying Medical Documentation - Upload a Document to Scribd

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

Free E and M coding / audit tool

2008-10-28T07:41:00.007-05:00

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

MedSpel 7.60 Released

2008-10-23T08:02:00.003-05:00

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.

MedSpel vs The Competition

2008-10-22T08:13:00.003-05:00

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

APACHE II calculator for Google Desktop

2008-10-14T21:43:00.001-05:00

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.

Making Medical Documentation Simple And Painless with MedicalTemplates

2008-09-01T22:17:00.000-05:00

Medical Templates Making Medical Documentation Simple And Painless

View SlideShare presentation or Upload your own. (tags: ehr emr)

Pneumonia Severity Index Google Gadget

2008-06-04T14:10:00.000-05:00

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.>

Creatinine Clearance Google Desktop Gadget

2008-05-22T10:59:00.000-05:00

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.>

GenericMedList Google Desktop Gadget

2008-05-14T13:45:00.006-05:00

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.

Medicare Reference Google Desktop Gadget

2008-05-13T19:06:00.004-05:00

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.

GenericMedList Search Widget

2008-04-16T20:49:00.003-05:00

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.

GenericMedList Searchgreat free widgetsWidgetbox

Wegmans $11.99 drugs added to GenericMedList

2008-04-03T15:02:00.003-05:00

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.

New Problem Specific MedicalTemplate Bundle

2008-03-11T21:48:00.004-05:00

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 -

Pleural Effusion

Chest pain

Pneumonia

COPD

Sepsis

Asthma

New Hypertension Management MedicalTemplate

2008-03-11T17:29:00.006-05:00

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.

Hypertension Follow up Evaluation - Upload a Document to Scribd

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

Save 15-25% on MedicalTemplate Bundles

2008-03-10T21:40:00.002-05:00

MedicalTemplate Bundles allow customers to save 15-25% when purchasing multiple MedicalTemplates.

MedicalTemplate Bundles Available
Primary Care (4 MedicalTemplates)
Chronic Disease Management (4 MedicalTemplates)
Pulmonary (5 MedicalTemplates)
Pulmonary Disease (6 MedicalTemplates)

New Sepsis Evaluation MedicalTemplate

2008-03-07T07:58:00.003-06:00

The sepsis evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected sepsis, SIRS, or septic shock.

The sepsis evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity, including critical care.

Sepsis Evaluation MedicalTemplate - Upload a Document to Scribd

Sepsis Evaluation Date Start time Stop time Patient Name Chief complaint/Reason for consult Patient DOB Referring MD MRN Allergies Allergy List reviewed No drug allergies No food allergies Medications History of Present Illness Patient is Nonverbal. History obtained from Family Medical records Medication list reviewed Medications reconciled with Nursing Home or Hospital discharge Information 46 Heart rate t 90 Temp d36 C or t 38 C Resp rate t 20 OR PCO2 d 32 on ABG WBC d4000 ORt 12000 OR t 10% Bands Positive blood culture = Sepsis PLUS = Systemic Inflammatory Response Syndrome PLUS SBP < 90; MAP d 70 mmHg OR drop of t 40 mmHg = Severe Sepsis PLUS Systolic BP d 90,or MAP d 70 = Septic Shock Social History Never Smoker Tobacco ____ # Packs X ____ # Yrs Quit Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems WNL Alcohol use Drinks per day week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day 1 “drink” is equal to 12 oz. beer,1.5 oz. 80-proof liquor, or 5 oz. glass of wine Constitutional Fatigue malaise fever/chills Appetite changes Eyes Vision changes New pain Scotomas ENT/mouth Nose bleeds Dental caries Dental abscesses Jaw pain Resp Dyspnea Cough Phlegm Hemoptysis Wheeze CV Chest pain Diaphoresis Ankle edema PND Syncope GI Nausea Weight changes Constipation Diarrhea Abdominal pain GU Change in urinary habits Hematuria Dysuria Musc Myalgias Recent trauma Bony fractures Arthralgias Joint swelling Skin/breasts Rashes Masses or skin lesions Increased sensitivity to sun Neuro Seizures Episodic or chronic muscle weakness Headaches Endo Hair loss Polydipsia Tremors Neck pain Heme/lymph Bleeding gums Unusual bruising Lymph nodes, tender or swollen Allergy/Immun Sinus probs Recurrent infections Psych Mood changes Agitation Psychosis Delirium Dementia Recreational drug use Inhalational Injectable Ingestible Drug dependence Narcotics Benzodiazepines Family Medical History Asthma Congestive Heart Failure COPD Coronary Artery Disease Premature Onset Malignancy Pancreatitis Peripheral Artery Disease Renal Dysfunction Thrombotic disorder Thyroid Disease Occupational and Exposure History 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 Chemicals or fires Trauma Vaccines Flu Pneumo BCG Tetanus Pertussis Varicella CABG Splenectomy Pituitary resection Organ transplant Other Surgeries Past Medical and Surgical History Asthma Adrenal dysfunction Arthritis Cerebral Artery Disease CHF COPD Coronary Artery Disease Cystic Fibrosis Diabetes 1 2 GERD Gout Hepatic dysfunction HIV/AIDS ©MB and RR 2006-2008 Hypertension Inflammatory Bowel Disease Malignancy Myocardial Infarction Neuromuscular weakness Pancreatitis Peripheral Artery Disease Renal dysfunction Thrombotic disease Thyroid disease, hyper Thyroid disease, hypo Seizure disorder Sleep Apnea Chemotherapy Colonoscopy ECHO/Stress test Immunosuppressive therapy Mammogram Organ failure PFTs Pap Smear Prior intubations Radiation exposure Sleep study Steroid use, chronic Strokes Revised7Aug08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures Sepsis Evaluation IV Medications & Labs Patient Name Exam Ventilator Mode Rate Patient DOB MRN Pressors Diuretics Heparin Thrombolytic Insulin Sedation Steroids Antibiotics TPN Narcotics Antiarrhythmics Crystalloids \____/ / \ ____ / ____ / ____ / \ \ \ AC SIMV + Pressure Support Pressure Control Pressure Support Airway Pressure Release PEEP PS FiO2 PO2/FiO2 Plateau Pressure Tidal Vol NonInvasive Ventilator (CPAP, BiPAP) Settings General Eyes ENT Neck Resp Clear to auscultation Clear to percussion CV Auscultation Palpation Edema Carotids Alert Vitals T P Conjunctivae Pupils Discs Nasal mucosa Dentition Oropharynx Normal to palpation Thyroid No JVD R BP Sats % Mallampati I II III IV GI No palpable masses Liver and spleen not palpable No hepatojugular reflux No abdominal/flank ecchymoses Lymph No lymphadenopathy Enlarged lymph nodes palpable Neck Axilla Groin Other Musc Gait Digit Inspection ROM Stability Strength Extrem No clubbing No cyanosis Skin Inspection Palpation Effort Normal to palpation Aorta Femoral pulses Pedal pulses Neuro Oriented 58(Pts with Community Acquired Bacterial Pneumonia) Psych Affect Orientation Insight Memory Additional Findings CN DTR Sensation Glasgow Coma Score E ____ V ____ M ____ Recommendations Impression APACHE II Score ____ APACHE IV Score _____ Aggressive pulmonary toilet DVT prophylaxis Stress ulcer prophylaxis Stop sedation daily assess neuro status Head of bed >30 Degrees at all times Insulin infusion Pneumonia vaccine prior to discharge Influenza vaccine prior to discharge Central line placement Central line change/removal Culture tip Physical therapy Enteral/Parenteral feeds CVP monitor placement Central or Mixed Venous O2 12-lead EKG Echocardiogram CBC CMP PT, PTT, INR Lactate Random cortisol level Toxicology Screen Blood Alcohol level Blood cultures x 2 Broad spectrum antibiotics Pseudomonas suspected Goal t 70% Goal CVP 8-12 Shock requiring Large volumes of Fluid Pressors Likely source of infection or ischemia present, describe Acute renal failure with chronic failure with ESRD Acute hepatic failure with chronic failure Acute heart failure Right Left with chronic failure Acute respiratory distress syndrome Acute respiratory failure with chronic failure Disseminated Intravascular Coagulation Adrenal Crisis OR Relative Adrenal Insufficiency Multiple Organ Dysfunction Syndrome Signature cc Patient has completed advanced health care directives47 HCPOA is Code Status Patient is a FULL CODE DO NOT ATTEMPT RESUSCITATION Data Reviewed: Care Coordinated with: ER Notes Chart Nursing Notes/Vitals log Labs Radiology data ECHO ECG Stress Test PFT HCPOA PCP Case Mgmt or SW Pharmacy Nursing Revised7Aug08 Indicates Physician Quality Reporting Initiative (PQRI) Physician Quality Measures ©MB and RR 2006-2008

New Diabetes chronic disease management MedicalTemplate

2008-03-07T07:54:00.004-06:00

The new diabetes evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected diabetes.

This MedicalTemplate is designed for chronic disease management.

The diabetes evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity.

Diabetes Evaluation - Upload a Document to Scribd

Diabetes 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 Med list Past Medical History Past Surgical History Social History Family Medical History Patient’s Blood Glucose log Recent labs Review of Systems Physical Exam General Eyes ENT Neck Resp CV GI Lymph Musc Extrem Skin Neuro Psych = Patient denies problems Constitutional ✔ Eyes Weight changes Fatigue Fever Vision changes Pain Ulcers Tooth pain Sore throat Dyspnea Cough Sputum Chest pain Exercise intolerance Nausea Vomiting Diarrhea ENT/mouth Resp CV GI GU Musc Dysuria Polyuria Discharge Myalgias Bony pain Alert Ht Wt BMI Pulse RR BP 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 No corns No ingrown nails Normal wear pattern on shoes Inspection Palpation Oriented CN DTR Sensation intact Vibratory sense intact Affect Orientation Insight Memory Additional Findings Skin/breasts Neuro Endo Impression & Plan Sores, ulcers Dry, cracked skin Numbness Paresthesias Hypoglycemia Tremors Heme/lymph Allergy/Immun Psych Easy bruising Swollen lymph nodes Sinus pain Nasal discharge Depression Anxiety Hallucinations Follow up This clinic Podiatry Last exam Ophthalmology Last exam Other Signature cc A1C Urinalysis CBC BMP LFTs Triglyceride level LDL and HDL BNP Cardiac enzymes Troponin TSH Auto-antibodies Islet cell insulin GAD65 IA-2 IA-2E Therapy Aspirin ACE-I or ARB Diuretic Statin Insulin Metformin Thiazolidinedione Secretagogue Other Labs ©MB and RR 2006-2008 Revised 4March08

New Gastroenterology MedicalTemplate

2008-03-07T07:50:00.003-06:00

The new gastroenterology evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected gastroenterology disorders such as abdominal pain, GI bleeding, liver disease, and pancreatitis. The gastroenterology evaluation MedicalTemplate is tailored to meet the needs of gastroenterologists, but is suitable for all health care professionals.

The gastroenterology evaluation MedicalTemplate includes all required E&M documentation elements for even the highest levels of complexity.

New Psychiatry MedicalTemplate published

2008-03-07T07:48:00.002-06:00

MedicalTemplates now includes a general psychiatry evaluation medical note template that can be downloaded from here.

The general psychiatry evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected psychiatric disorders such as depression and bipolar disorder. This MedicalTemplate includes all the required elements for the high complexity E&M documentation, tailored for the needs of mental health professionals.

OpenMedSpel on Mozdev

2008-03-05T15:23:00.004-06:00

OpenMedSpel, our free and open source medical spelling word list, is now available on Mozdev.org.

About Mozdev.org

Mozdev.org is a software development community dedicated to making quality applications and extensions freely available to all computer users. The goal of Mozdev.org is to help establish Mozilla as a viable application development platform.

About Mozilla

The mission of the Mozilla project is to preserve choice and innovation on the Internet. The Mozilla project is the producer and provider of the award-winning Firefox web browser and Thunderbird e-mail software.

ProfileMD will run on Palm Centro Smartphone

2008-02-18T18:20:00.005-06:00

Our ProfileMD Classic personal health record functions properly on the new Palm Centro smartphone available in the USA through Sprint.

Centro Features

320x320 pixel, 65K color screen
64MB of storage memory
1.3 megapixel camera
Removable battery
microSD memory card slot

Free Health Care Consumer Questionnaire Released

2008-02-18T07:44:00.003-06:00

The FREE Health Care Consumer Questionnaire is a comprehensive medical history form designed to be filled out by the health care consumer prior to a visit with a health care provider.

This MedicalTemplate is appropriate for a new patient evaluation or any visit to a health care provider.

The Health Care Consumer Questionnaire can also be used as a personal health record.

New Patient form - Upload a Document to Scribd

New Health Care Consumer Questionnaire Patient Name ________________________________ DOB ____/____/________ Date ____/____/________ In order to best serve your medical needs, we ask that you complete the following questionnaire as completely as possible. The Health Care Consumer (HCC) - Health Care Provider (HCP) relationship is a privileged relationship built on trust and honesty. By completing and signing this form, you acknowledge that you understand that any intentionally false information may seriously and adversely affect your health. Patient Name ___________________________________________________________________ Gender Last First Middle Date of Birth (MM/DD/YYYY) M F ______/______/__________ Social Security Number _____ - _____ - _______ If the person completing this form is not the patient, please write your name, your relationship to the patient, and why you are completing the form for this patient. Name__________________________Relationship________________Reason_____________________ Reason For Visit _____________________________________________________________________ Patient’s Personal Contact Information (Address and Phone) ____________________________________ ____________________________________ Emergency Contact (Address and Phone) Home Phone _____________________________ Work Phone _____________________________ ____________________________________ ____________________________________ Home Phone _____________________________ Work Phone _____________________________ Insurance Information (Insurance Company, Policy Number, Contact Number) ____________________________________ Policy#______________________________ Additional, or Secondary Insurance Company Contact # _____________________________ Fax (if known) _____________________________ ____________________________________ Policy#______________________________ Contact # _____________________________ Fax (if known)______________________________ Have you completed a Living Will OR designated a Durable Power of Attorney for Health Care? If yes, please provide a copy for your health care provider. Do you have any religious or cultural beliefs that may impact your health care? If yes, please describe Yes No Yes No ___________________________________________________________________________________ Methods of learning new material that I like best are: Verbal Instruction Written Instruction Handouts Visual (Pictures, Videos, etc) You Do You Do Not understand English well. The language you prefer _____________________ Level of education completed <6th grade 6th – 8th grade 9th grade 12th grade 1-4 years college >4 years college MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 1 New Health Care Consumer Questionnaire Patient Name ________________________________ DOB ____/____/________ Date ____/____/________ Names and Phone Numbers for Health Care Providers (HCPs) from whom you are currently receiving care (or have seen within the past 12 months), AND ANY Health Care Providers from whom you are obtaining prescriptions. _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ _____________________________ Contact #__________________________ Contact #__________________________ Contact #__________________________ Contact #__________________________ Contact #__________________________ Contact #__________________________ Please list all of the medications you are taking. Include over the counter medications, herbs & vitamins. Medication Name Dose Last taken Medication Name Dose Last taken ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ ___________________________________ Please list and describe allergic reactions you have had to food, medications or insect stings. Check if you are you allergic to Shellfish ___________ IV Contrast Dye __________ Penicillins __________ Please list Food, Medication or Insect Allergies ___________________________________ ___________________________________ ___________________________________ ___________________________________ Reaction ___________________________________ ___________________________________ ___________________________________ ___________________________________ MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 2 New Health Care Consumer Questionnaire Patient Name ________________________________ DOB ____/____/________ Date ____/____/________ Please list your occupations. Include the length of time you performed in that role, and describe your work responsibilities in that occupation. (Include military experience.) Occupation ________________ ________________ ________________ ________________ ________________ Start Date ________ ________ ________ ________ ________ Stop Date _________ _________ _________ _________ _________ Responsibilities ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ ____________________________________________ Have you ever been exposed to known cancer causing agents or inhalation hazards? Yes No Examples: asbestos, paints, aniline dyes, chemicals, silica, etc. If yes, please list types of exposure, time period exposed, and health problems experienced at time of exposure Agent ________________ ________________ ________________ Start Date ________ ________ ________ Stop Date _________ _________ _________ Health problems resulting from exposure ____________________________________________ ____________________________________________ ____________________________________________ Please describe your hobbies. _______________________________________ _______________________________________ _______________________________________ _______________________________________ Have you traveled, in the past 1 year? Yes No If so, please describe where, when, and for how long you were there. Travel destinations OUTSIDE the United States _______________________________________ _______________________________________ Travel destinations INSIDE the United States _______________________________________ _______________________________________ Dates spent at this destination _______________________________________ _______________________________________ Dates spent at this destination _______________________________________ _______________________________________ Do you exercise? Yes No If yes, describe how long and how often you exercise on average each week __________________________________________________________________________________ __________________________________________________________________________________ In the past 12 months, have you fallen? Yes No If yes, how many times? ______ If yes, have you ever broken bones, or sustained an injury, as a result of falling? Yes No MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 3 New Health Care Consumer Questionnaire Patient Name ________________________________ DOB Do you have a history of smoking? Have you ever chewed tobacco? Have you ever smoked pipes or cigars? Have you quit? If so, when. Have you considered quitting? Have you tried quitting? ____/____/________ Date ____/____/________ Yes Yes Yes Yes Yes Yes No If yes, ______ # packs per day X ______ for # years No No If yes, how many cigars or bowls _____ per Day Week No __________________________________________ No If yes, have you set a date to quit? Yes No No If yes, what is the longest time period you quit smoking? ________ Do you have a history of alcohol use? Yes No If yes, specify _______ # drinks per Day Week 1 “drink” is equal to 12 oz. can of beer, 1.5 oz. liquor (80 proof) or 5 oz wine Have you ever experienced a blackout, or loss of consciousness due to alcohol intake? Have you ever needed to drink to prevent yourself from shaking, sweating, and becoming irritable? Have you ever been arrested or ticketed for DUI (Driving Under the Influence)? Have you been involved in any motor vehicle accidents in the past 12 months? Yes Yes Yes Yes No No No No Do you use drugs for recreational purposes? Yes No If yes, check all that apply Amphetamines Cocaine Marijuana Heroin Inhalants LSD Method of delivery you chose Ingestion Injection Inhalation How much would you use _________________________________________________________________ How long did you use drugs ______________________________________________________________ Have you quit? Yes No If so, when __________________________________________________ Have you ever taken drugs to prevent shaking, sweating and becoming irritable? Yes No Have you ever had a problem with addiction to prescription pain medication or benzodiazepines? Yes No If yes, specify when and which drugs. _____________________________________________ Are you sexually active? Yes No If so, do you practice birth control of any kind? Yes No If yes, check below all that apply Condoms Diaphragm IUD (Intrauterine Device) Birth Control Pills, Patches, Implants How many sexual partners have you had in the past 1 year? Have you ever had sex with a person who is the same gender as yourself, bisexual, or anyone who performs sexual favors in exchange for money or drugs? Yes No Have you EVER been diagnosed with a sexually transmitted disease (like syphilis, gonorrhea or HIV), or were you exposed to a sexually transmitted disease during childbirth? Yes No Do you have any tattoos or body piercings? Yes No Have you received any transfusions of blood or blood products? Yes No Describe your seatbelt use when you are driving, or a passenger in a vehicle All the time Most of the time About half the time Rarely Never Do you keep firearms in your place of residence? Yes No If yes, are they kept in locked compartments, or do they have safety locks? Yes No Can you perform your own hygiene, dressing, cooking and shopping needs independently? Yes No Do you feel safe in your relationship? Yes No Have you ever been in a relationship where you were threatened, hurt or afraid? Yes No MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 4 New Health Care Consumer Questionnaire Patient Name ________________________________ DOB Have you ever had the following exams? If so describe when and why PAP Smear Prostate Biopsy Mammogram Colonoscopy ____/____/________ Date ____/____/________ Yes No ________________________________________________ Yes No ________________________________________________ Yes No ________________________________________________ Yes No _______________________________________________ EGD (Esophageal endoscopy) Yes No ________________________________________________ EKG Cardiac stress test ECHO Chest x-ray CT “CAT” scan of chest Pulmonary function test EEG Bone density test Yes No _______________________________________________ Yes No _______________________________________________ Yes No _______________________________________________ Yes No _______________________________________________ Yes No _______________________________________________ Yes No _______________________________________________ Yes No _______________________________________________ Yes No ________________________________________________ Have you had any of the following vaccinations? Check all that apply, and specify when last received. Yes Yes Yes Yes Yes Yes No No No No No No Influenza Pneumonia Tetanus BCG Varicella HPV (Gardasil) __________________ __________________ __________________ __________________ __________________ __________________ If you are female, have you ever been pregnant? Yes No If yes, please describe Number of pregnancies? ______ Number of live births? ______ Number of miscarriages or abortions? _____ Age of onset of menstrual cycles? ______ Age of onset of menopause? ______ NA Have you ever taken birth control pills, or used birth control patches or implants? Yes No If yes, what did you take and for how long? ___________________________ Have you ever been on hormone replacement therapy? Yes No If yes, what did you take and for how long? ___________________________ Did you ever have an IUD? Yes No If yes, was it removed? If yes, when __________ MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 5 New Health Care Consumer Questionnaire Patient Name ________________________________ DOB Past Medical History Please check all that apply. Adrenal Dysfunction Alzheimer Amyotrophic Lateral Sclerosis Anorexia or Bulimia Anxiety Disorder Arteriovenous Malformations (AVMs) Arthritis Asthma Autoimmune Disease Bipolar Disorder Bleeding Disorder Cataracts Cerebrovascular Accident (Stroke) Chemotherapy If yes, state when Claudication Clotting Disorder Congenital Heart Defects Coronary Artery Disease COPD Cystic Fibrosis Depression Diabetes Dialysis Eclampsia or Pre-eclampsia Endocarditis Endometriosis End Stage Renal Disease Erectile Dysfunction Esophageal Dysfunction Fibromyalgia Gallstones Gastritis or Gastric Ulcers GERD (reflux problems) Glaucoma Heart or Valve Defects Hemochromatosis Hemorrhoids Hepatitis HIV or AIDS Hypertension Hyperthyroidism Hypotension Hypothyroidism Inflammatory Bowel Disease ____/____/________ Date ____/____/________ Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No Irregular Heart Rhythm Kyphosis Liver Dysfunction Kidney Failure, or Dysfunction Malignancy If yes, describe below Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No No Mania Muscular Dystrophy Myocardial Infarction (Heart Attack) Narcolepsy Obstructive Sleep Apnea Organ Transplant If yes, describe Osteoporosis Pancreatitis Periodic Limb Movement Disorder Peripheral Artery Disease Personality Disorder Pituitary Dysfunction Polycystic Ovarian Syndrome Pulmonary Artery Hypertension Pulmonary fibrosis Radiation Therapy If yes, explain Recurrent Infections Restless Leg Syndrome Sarcoidosis Schizophrenia Scleroderma Scoliosis Seizure Disorder Sickle Cell Sjogren Skin Disorders (Psoriasis, Acne) Thalassemia Thrombocytopenia Thrombophilia Transfusions Tuberculosis If yes, have you been treated? Urinary retention or urgency Vasculitis Visual defects Vocal cord dysfunction/paralysis MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 6 New Health Care Consumer Questionnaire Patient Name ________________________________ DOB ____/____/________ Date ____/____/________ Review of Systems In the last 6 months, have you experienced any of the following symptoms? Respond to each. Constitutional Weight Loss or Gain Appetite changes (increased or decreased) Fatigue, profound and impairs daily function Fever Shakes/sweats from lack of alcohol or drug Yes Yes Yes Yes Yes No No No No No Genitourinary Blood in your urine Menstrual changes Urinating that is painful or difficult Erection problems Vaginal discharge or bleeding Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Eyes Eye pain or drainage Visual changes Dry, irritated eyes Yes No Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No No No No No ✔ No No No No No No Musculoskeletal Broken bones Joint pain or swelling Muscle aches Muscle weakness Back pain ENT/Mouth Ear pain or drainage Frequent sinus infections Hearing changes or loss Nosebleeds Dizziness Skin/Breasts Masses or lumps Nipple discharge Rashes or nonhealing ulcers Yes No Yes No Yes No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No Respiratory Blood in your sputum Chest tightness Cough lasting >1 month, productive or not Shortness of breath Wheezing Chest pain with inhalation or coughing Neurologic Seizures Coughing or choking with swallowing Excessive daytime sleepiness Extremity pain or burning sensations Hallucinations Numbness or tingling Difficulty falling asleep, staying asleep Cardiovascular Chest pain or heaviness Palpitations Fainting or near fainting spells Swelling of feet or legs Shortness of breath lying flat in bed Endocrinologic Hair loss Frequent urination Increased thirst Heat or cold intolerance Gastrointestinal Abdominal pain Blood in your stool Constipation Diarrhea or Food Intolerance Heartburn or Indigestion Vomiting or nausea lasting for >1 day Swallowing difficulty Heme/Lymph Bleeding from gums or nose Unexplained bruising Night Sweats Swollen, painful lymph nodes Psych Anxiety without clear explanation Sadness lasting for days or weeks Hearing voices Thoughts of hurting yourself Thought of hurting others Fear of people, places or things Allergy/Immun Watery eyes Runny nose Food intolerance Frequent skin sores MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 7 New Health Care Consumer Questionnaire Patient Name ________________________________ DOB ____/____/________ Date ____/____/________ Please list all surgical procedures you have had. Please include surgeon and date of procedure. _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ _______________________________________ Family Medical History Please list all known medical problems in your immediate family. (Specify M=Mother, F=Father, B=Brother, S=Sister, So=Son, D=Daughter, GM=Grandmother, GF=Grandfather) _________________ _________________ _________________ ______________________ ______________________ ______________________ ____________________ ____________________ ____________________ ___________________ ___________________ ___________________ Additional Information that you feel may be helpful for your health care provider to know. __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ Health Care Provider Notes __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ __________________________________________________________________________________ MB & RR 2008 e-medtools.com The information on this page was reviewed with the patient HCC Initials _____ HCP Initials _____ 8

The Health Care Consumer Questionnaire is a detailed 8-page snapshot of an individual’s current and past medical problems.

Information included in the Health Care Consumer Questionnaire

Allergies
Medications
Surgeries
Past Medical History
Family Medical History
Review of systems
Social History
Religious and cultural beliefs
Travel history
Occupational history
Carcinogen exposure history
Behavioral risk factors

OpenMedSpel for Mozilla Products released

2008-02-17T22:51:00.001-06:00

OpenMedSpel is a open source USA English medical spelling word list that is released under a GPL license for Mozilla Firefox, Mozilla Thunderbird, and SeaMonkey.

	Install Instructions
	Install Instructions

GenericMedList Toolbar

2008-02-15T14:47:00.004-06:00

GenericMedList now has a free search toolbar that can add GenericMedList to FireFox or Internet explorer. The GenericMedList Toolbar also includes our RSS news feeds and will notify users about updates to GenericMedList.

toolbar powered by Conduit

Add GenericMedList to search bar on Firefox and IE 7

2008-02-11T12:53:00.001-06:00

GenericMedList custom search can be added to the Firefox 2.0 and Internet Explorer search bars.

To add GenericMedList search to your search bar, visit GenericMedList.com.

Select the search engine list, and add GenericMedList.

GenericMedList search will now appear in your search bar.

MedicalTemplate updates for 2/11/08

2008-02-11T08:01:00.002-06:00

The latest MedicalTemplates that have been updated are:

The updated templates include a digital signature field and an improved layout.

MedicalTemplate Updates

2008-02-08T07:50:00.001-06:00

The lung mass, pulmonary clinic initial evaluation, and primary care follow up MedicalTemplates have been updated with an improved format and quality reminders for the Medicare PQRI program.

GenericMedList offers iPhone optimized content

2008-02-07T10:41:00.001-06:00

GenericMedList.com is now enhanced by the iWPhone WordPress Plugin to deliver content optimized for the screen size and Safari browser of the iPhone and iPod Touch.

Update for downloadable GenericMedList

2008-02-03T18:14:00.002-06:00

The downloadable version of GenericMedList has been updated and can be downloaded from here.

This 4 page list details the generic drug discount programs at Walmart, Target, KMart, and Kroger stores. The free antibiotics programs at Meijer, Publix, and Schnucks stores is also included.

This one of a kind reference is a useful tool to anyone trying to select the most affordable medications.

Overview of 2008 Medicare PQRI Program

2008-01-17T12:16:00.001-06:00

| View | Upload your own

Schnucks Free Antibiotic Program Added To GenericMedList

2007-11-11T12:26:00.001-06:00

Schnucks stores announced a free generic antibiotic program on 10/28/2007. Schnucks pharmacies will provide a free 21 day supply of select antibiotics with a prescription.

The list of generic antibiotics included in the Schnucks program can be found at GenericMedList.com

More Information
Article in St Louis Post-Dispatch
Official Schnucks Program Website

Kroger $4 Drug list added to GenericMedList

2007-10-24T22:18:00.002-05:00

Kroger stores announced generic medication discount program October 12, 2007 at select Kroger stores. Kroger now prices selected generic drugs at $4 for a 30 day supply.

The list of generic drugs included in the Kroger program can be found at GenericMedList

New Pulmonary Artery Hypertension MedicalTemplate

2007-10-01T12:22:00.002-05:00

A new pulmonary artery hypertension MedicalTemplate was released 10/1/07.

The pulmonary artery hypertension evaluation MedicalTemplate is suitable for any health care provider that manages patients with known or suspected pulmonary artery hypertension in inpatient and ambulatory settings.

Tags: Pulmonary hypertension, medical template, medical documentation

Pulmonary Arterial Hypertension Evaluation - Upload a Document to Scribd

Pulmonary Arterial Hypertension Evaluation Date Start time Stop time Allergies History of present illness Fatigue, weakness Cough Pain Decreased appetite Hemoptysis Weight loss Calcinosis Raynaud’s Esophageal dysfunction Sclerodactyly Telangiectasias Dyspnea Asymptomatic with usual activity Symptomatic with usual activity Symptomatic with minimal activity Symptomatic at rest Chief complaint/Reason for consult MRN Allergy list reviewed No drug allergies No food allergies Medications Medication list reviewed Med list reconciled with Nursing Home, Skilled Nursing facility or Rehab facility med list 46 Social History Tobacco use ____ Packs x ____ Yrs Chronic exposure to second hand smoke Daily, occasional and ex-smokers are more likely to be hazardous drinkers Review of Systems See HPI WNL Quit Alcohol use ______ Drinks per day week Hazardous drinking NIAAA (National Institute on Alcoholism and Alcohol Abuse guidelines) Men > 14 drinks per week OR > 4 drinks per day Women > 7 drinks per week OR >3 drinks per day Recreational drug use Inhalational Injectable Ingestible Drug dependence Narcotics Benzodiazepines Constitutional Eyes ENT/mouth Resp CV GI GU Musc Skin/breasts Neuro Endo Heme/lymph Allergy/Immun Psych Occupational History Fatigue, malaise, change in appetite Vision changes, new pain, scotomas Nose bleeds, dental Caries, dental abscesses, jaw pain Phlegm, wheeze, witnessed apnea, excessive daytime sleepiness Chest pain, diaphoresis, ankle edema, PND, syncope Emesis, dysphagia, GERD, abdominal pain, diarrhea, melena Change in urinary habits, hematuria, dysuria Myalgias, recent trauma, bony fractures, arthralgias, joint swelling or redness Rashes, new masses or skin lesions, increased sensitivity to sun exposure Headache, Paresthesias, Muscle weakness, difficulty with speech, seizures, tremor Hair loss, polydipsia, polyuria, gynecomastia Bleeding gums, unusual bruising, swollen lymph nodes Sinus probs, recurrent infections, anaphylaxis Mood changes, agitation, psychosis, delirium, dementia Family Medical History AV Malformations Pulmonary Hypertension Rheumatoid Arthritis Scleroderma Systemic Lupus Erythematosus Malignancy Breast Colon Lung Melanoma Prostate Renal cell Testicular Thyroid Other Past Medical and Surgical History Asthma Appetite Suppressant Use Neuromuscular weakness Bronchiectasis AV Malformations Occupational exposures Cryptogenic Organizing Pneumonia (BOOP) Cerebral Artery Disease Peripheral Artery Disease COPD Congenital Heart Defects Scleroderma Cystic Fibrosis Left to Right Shunt Seizure Disorder Histiocytosis Atrial Septal Defect Sjogren Obstructive Sleep Apnea Ventricular Septal Defect Systemic Lupus Erythematosus CPAP BiPAP Patent Ductus Arteriosus Renal Dysfunction Tuberculosis Congestive Heart Failure Rheumatoid Arthritis Pulmonary Arterial Hypertension Coronary Artery Disease Thrombotic Disease Pulmonary fibrosis Dermatomyositis/Polymyositis Thyroid Disease Pulmonary Thromboembolic Disease Diabetes Malignancy Pulmonary Venoocclusive Disease Diastolic Dysfunction Breast Sarcoidosis Nocturnal GERD Colon Tuberculosis Hepatic Dysfunction Lung Surgeries HIV/AIDS Melanoma Hypertension Prostate Inflammatory Bowel Disease Renal cell Mitral Stenosis or Regurgitation Testicular Mixed Connective Tissue Disorder Thyroid Myocarditis/Pericarditis Other ©MB and RR 2006, 2007 Revised 26Sep07 Pulmonary Arterial Hypertension Evaluation Vitals Weight BMI Temperature BP Pulse Sats At Rest With Activity CVP Cardiac Output Urine Output Last 24 hours Last 8 hours Exam ✔ Checked box indicates findings are within normal limits Alert Nasal mucosa Dentition Oropharynx Mallampati I II III IV Neck Normal to palpation Thyroid No JVD Resp Clear to auscultation Dullness to percussion No respiratory distress No chest wall defects Decreased fremitus Bronchial breath sounds CV Clear S1 S2 No murmur No gallop No rub Peripheral pulses No peripheral edema GI No palpable masses Liver and spleen not palpable No hepatojugular reflux Lymph No lymphadenopathy Musc Tone Gait Extrem No clubbing No cyanosis Skin No rashes, ecchymoses, nodules, ulcers Neuro Oriented Affect General ENT Glasgow Coma Score E____ V____ M____ APACHE II Score ____ Impression and Plan Schedule Patient For Labs/Tests LFTs Hepatitis Panel HIV TSH CBC BMP D-dimer ESR Phospholipid Ab RF dsDNA Ab ssDNA Ab Centromere Ab Topoisomerase I Ab (Scl-70) U1RNP Ab Jo-1 Ab Pulmonary Function Testing Methacholine Challenge 6 Minute Walk Test CXR Chest CT with contrast V/Q Scan ECHO With Bubble study Assess PA pressures Cardiopulmonary Stress Test Sleep Study Bronchoscopy Pneumococcal vaccine Influenza vaccine Signature Patient has completed advanced health care directives47 Health Care Power Of Attorney is Code Status Full code Do Not Attempt Resuscitation Continuous home oxygen Tx Flow rate ____________L/min Concentrator Tank with conservation valve Nasal cannula with reservoir Portable tank Gas Liquid Supplemental oxygen therapy during air travel Flow rate ____________L/min Home CPAP BiPAP Flow rate ____________L/min Heater and humidifier Mask type Nasal Oronasal Face ©MB and RR 2006, 2007 Revised 26Sep07

New Chest Pain MedicalTemplate

2007-10-01T12:16:00.001-05:00

Our new chest pain evaluation MedicalTemplate was released 10/01/07.

This new MedicalTemplate is suitable for any health care provider that manages patients with chest pain in inpatient and ambulatory settings.

The American Heart Association reports that 8.9 Million people experience angina (cardiac chest pain) each year, and that 400,000 new cases of angina are diagnosed each year. Angina is the most common symptom of heart disease, which is the leading cause of death for men and women in the United States. The CDC reports that 29% of the deaths in 2002 (the most recent year with published statistics) were due to heart disease. More women than men died of heart disease in 2002.

Because of the prevalence and significance of cardiac related chest pain, a comprehensive cardiac evaluation forms the cornerstone of any chest pain evaluation. However, other causes of chest pain such as pulmonary embolisim, pneumonia, pericarditis, esophagitis, and aortic dissection must also be considered.

How to reclaim money your practice may be throwing away

2007-09-27T13:19:00.000-05:00

Slideshow Transcript
Slide 1: How To Reclaim Money Your Practice May Be Throwing Away The Cost of Inadequate Documentation and Incorrect Coding e-medtools.com

Slide 2: Basic Premises Most physicians Are not practicing medicine “for the money!”  Are competent, compassionate doctors  Enjoy helping others  Work long, hard, often thankless hours  Deserve the money they earn! 

Slide 3: Stressors Physicians Experience Rising clinic practice costs Generally 40-60% of a physician’s revenue Practice costs expected to increase 20% in 2008 Decreased reimbursement from insurance companies Increasingly complex medical field Increased requirements and cost for maintaining licensure Increased pressure to improve quality without compensation Exorbitant, rising medical liability costs and jury awards Increasing violence directed at healthcare workers 28% of ED physicians are assaulted each year Annals of Emergency Medicine 2005 46(2):142-7

Slide 4: Additional Stressors Unrealistic expectations from the general public, legislators, lawyers, and insurance companies Idealistic, virtually perfect performance from physicians Quality is an unfunded mandate! Essentially free medical care is a “moral imperative” (Hillary Clinton’s, 2008 Presidential Candidate, address to George Washington University Medical News Today May 2007) Healthcare providers will bear the cost of public health Emergency departments must treat all people who walk through their doors regardless of ability to pay Hospitals require that doctors be on call for the emergency department in order to have the privilege of working at that hospital Doctors must then see patients who cannot pay for their care

Slide 5: There is No Free Lunch Food, Shelter, Clothing and Healthcare Should the government provide these for free? Should businesses be required to provide these for free? Why should doctors provide free healthcare?

Slide 6: What Physicians Already Do “Physicians are an important source of healthcare for many uninsured and underinsured patients, as evidenced by the fact that a physician’s office is the usual source of care for about one third of uninsured persons, and physician uncompensated care costs were estimated as high as $11 billion in 1994” Managed Care and Physicians’ Provision of Charity Care JAMA 1999 281:1087-1092 Physician Survey (American Medical News 2006) 76% of physicians provided free or low cost healthcare in 1996-97 68% of physicians provided free or low cost healthcare in 2004-2005 Physicians spent 10.6 hours/week providing uncompensated care! “A Growing Hole in the Safety Net: Physician Charity Care Declines Again” Center for Studying Health System Change 2006

Slide 7: Impact of Physician Stressors Medical practices are BUSINESSES!  – A business is not sustainable unless income exceeds expenses – Unlike most businesses, medical practices (physicians) are legally restricted in setting fees for services Reimbursement for physician services are decreasing,  therefore physicians must – See more patients to sustain the medical practice – Spend less time with individual patients in order to see more patients The consequences of an increased workload can result in  – An increased likelihood of missing problems – Decreased patient satisfaction – A significant drop in physician job satisfaction – Hastened “burnout”

Slide 8: To Err Is Human . . . But Don’t Err On Insurance Documentation! Incorrect billing for the documentation provided  Regardless of the complexity, lack of clarity, and unending changes made IS ASSUMED TO BE FRAUD! to the system And can turn a doctor into a criminal! In less time than it takes to receive payment from the Centers for Medicare and Medicaid!

Slide 9: The Injustice Demands from insurance companies are increasing -more paperwork, denial hassles, phone calls, audits, etc. Meanwhile Physician practice costs have  increased by 20% since 2001 (AMA) Health insurance costs have nearly doubled  Yet insurance companies are reducing reimbursement to physicians! – By 2013 it is predicted that Medicare reimbursement will be 50% of the reimbursement seen in 1991! (Vital Signs March 2005) – 2008 Medicare cuts will average 9.9% (AMA) – 5% cuts are planned for 2009 (AMA News, Aug 2007)

Slide 10: How Can Physicians Afford To Work? Give up coveted independence in favor of employed positions?! Stop seeing Medicare and Medicaid patients?! (MMWR 56(10);230) In 2004 20% of physicians no longer accepted Medicare patients 9.3% no longer accepted Medicaid 60% of physicians interviewed in 2007 by the AMA state that they will limit the number of new Medicare patients as a result of aggressive, proposed cuts to physician reimbursement (AMA) Surviving requires understanding AND playing the insurance game! Maximize reimbursement through Adequate and thorough documentation Appropriate Coding Get Paid For The Work You Do!

Slide 11: Many Physicians Under Code! Most physicians do more work than their documentation supports! And, as the saying goes, if it isn’t documented, it didn’t happen! Fear of fines and loss of licensure have forced physicians into under-coding!

Slide 12: How Much Is At Stake? 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”) Assumptions $30 difference in reimbursement (99213 to a 99214) 30 patients per day = lose ~$300 per day! [33%(30 patients/day) x $30/patient = $300/day] For a physician working 5 days/week for 50 weeks, that is $75,000 annually per physician!!! That’s no small chunk of change!

Slide 13: 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 775 (99213) patients/year  Or, an extra 3 patients/day!  WITHOUT THE EXTRA WORK!  $40,000 per year / $58 per patient = 690 patients per year  690 patients per year / 250 work days per year ~ 3 patients per day  Put another way . . .  Losing $300 per day is like seeing nearly 3 new patients per day for free! ($90 per each 99203 new patient) This won’t make physicians rich! This merely decreases the impact of ongoing losses due to decreasing reimbursement and shifting healthcare costs!

Slide 14: Tools to Improve Documentation Electronic Medical Records (EMRs)  – Electronic medical records are available, but are often cost-prohibitive Standardized forms  – Proven to improve documentation – Less expensive – Most are designed to be completed by hand and kept in a paper chart – Many are specific for particular complaints  such as cough, sore throat, etc.,  yet lack the scope needed to address multiple comorbidities – Few contain reminders Physician Quality Reporting Initiatives  Risk of excessive alcohol intake  Severity index scoring, etc. 

Slide 15: Electronic Medical Records In 2004 President Bush created the Office of the  National Coordinator for Health Information Technology whose mission is to – “Implement an interoperable health information technology infrastructure nationwide” System costs  – Software, hardware, training, implementation, ongoing maintenance and support Induced costs  – Costs involved in the transition to an electronic medical record, such as the temporary decrease of productivity A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403 E-Health 101:Electronic Medical Records Reduce costs, Improve care, and Save lives American Electronics Association 2006

Slide 16: Electronic Medical Records Capabilities May Include* Viewing  – Medical notes, labs, reports, formularies Documenting  – Medical notes, labs, reports Ordering  – Prescriptions, labs, tests, consults, durable medical equipment Messaging  – Physician-Staff; Physician-Physician; Physician-Patient and vice versa Care Management/Follow up  Analysis and Reporting  – Adverse drug reactions, drug-drug reactions, chronic disease reminders, preventive care reminders, statistical analysis Patient-directed  Billing and Scheduling  * All capabilities are not available for all EMR systems

Slide 17: Who Uses Electronic Medical Records? ~ 25% of office-based physicians used some form of EMR in 2005 National Center for Health Statistics National Ambulatory Medical Care Survey

Slide 18: Implementing Electronic Medical Records $2,500 - $44,000 initial start-up cost/provider  – Software  50-200% of initial costs – Hardware  $5,000-10,000/provider – Implementation  $3400/provider – Additional maintenance costs  $700-1500/provider per month  Providers include MD, NP, RN, LPN, PA, MA, receptionist Lost productivity estimated at >$10,000 in the first year  Average time to return on investment is 2.5 years  – This makes electronic medical records unobtainable by most medical practices The Value of Electronic Health Records in Solo or Small Group Practices Health Affairs 2005 24(5):1127-1137 A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403 Electronic Medical Records Systems Cost Effective, Study Shows Medical News Today 2007

Slide 19: Benefits of Electronic Medical Records Improved documentation  Reduce paper chart pulls  – Estimated to cost $5/chart Decrease costs for transcription  Reduce redundant labs and tests ordered  Some provide prompters  – Preventive care – Medication options – Adverse drug interactions A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403

Slide 20: Financial Benefits of EMRs 5-year net BENEFIT of a “full EMR”  – $86,000/provider – Full EMR includes electronic prescriptions, chronic disease reminders, drug interactions, and preventive care prompters 5-year net COST of a “light EMR”  – $18,000/provider – used only to reduce paper chart pulls and transcription costs A Cost Benefit Analysis of Electronic Medical Records in Primary Care The American Journal of Medicine 2003 114(5):397-403

Slide 21: MedicalTemplates Standardized patient encounter forms   Adobe PDF Technology – Use as a paper form OR – Use as an electronic form

Slide 22: MedicalTemplates Features Documentation prompters  – HCFA 1997 documentation guidelines Quality reminders  – Medicare PQRI Checkboxes  – Save time – Save energy – Time is Money

Slide 23: Implementing MedicalTemplates Required Hardware and Software – Free Adobe Reader from Adobe.com – Basic computer ($350 or less)  Intel Pentium III or better for Windows  PowerPC G3 or better for MacOS – One or more MedicalTemplates  $150 per template

Slide 24: MedicalTemplate Benefits Inexpensive implementation   Minimal learning curve  Improved documentation  Reduce paper chart pulls (if using electronic format) – Estimated to cost $5/chart Decrease costs for transcription   Prompters/Reminders improve – Preventive care – Quality of care – Treatment options – Evaluation options

Slide 25: MedicalTemplates ROI Assumptions Template cost $150 per practitioner  Computer cost $350 (most offices already have >1 computer)  Baseline under coding rate 30%  ($300 lost revenue/day) Reduction in under coding 50%  – If 33% of 30 patients seen in one day are under coded  10 patients are under coded by $30 apiece = $300/day  A 50% reduction = Only 5 patients are under coded  Increased revenue = $30 x 5 patients now coded correctly = $150 Increased revenue of $150/day equates to a savings of  $750/week $3000/month >$36,000/year! At $150 per template, the template pays itself off in 1 day!

Slide 26: MedicalTemplate ROI Calculation Including Computer Costs In just 1 month, the Return On Investment (ROI) could be: Average improvement in reimbursement in 1 month X 100 = ROI Cost of Template + Cost of Computer $3000 X 100 = 600% $150 + $350

Slide 27: MedicalTemplate ROI Calculation Without Computer Costs In just 1 month, the Return On Investment (ROI) could be: Average improvement in reimbursement in 1 month X 100 = ROI Cost of Template $3000 X 100 = 2,000% $150

Slide 28: Time to Recover Cost of MedicalTemplate MedicalTemplate + Computer ($500) $500/$150 ~ 3 days MedicalTemplate without Computer ($150) $150/$150 = 1 Day!

Slide 29: Savings Not included in ROI Estimates Reductions in down coding   Reductions in claim denials  Reduced time spent on documentation  Reduced time pulling charts

Slide 30: MedicalTemplates General forms Problem specific forms Clinic H&P Asthma   Clinic Follow Up Note COPD   Hospital H&P Pneumonia   Hospital Follow Up Pleural Effusion   Pulmonary/Critical Care H&P  Lung Mass  Pulmonary/Critical Care Follow  Interstitial Lung Disease  Up Chest Pain  Pulmonary Clinic H&P  Pulmonary Hypertension 

Slide 31: MedicalTemplates MedicalTemplates has created multiple medical templates appropriate for evaluating patients in the clinic or hospital setting. MedicalTemplates are fillable PDF forms that allow the physician to type historical information directly into the form. They can be saved electronically for later reference. Documentation time is decreased Most components of the history and physical exam can be completed by checking the appropriate box. Reducing documentation time by 5-10 minutes per patient could save the physician >2 hours per day! 30 patients / day x 5 minute decrease / patient = 2.5 hours / day SAVED!

GenericMedList added to the dotMobi Showcase

2007-09-27T09:24:00.001-05:00

GenerciMedList.mobi has been added to the dotMobi Showcase at http://mtld.mobi/showcase, and has scored 5/5 at Ready.Mobi

The .mobi domain requires the use of stringent W3C-based standards to ensure a high quality mobile user experience. GenericMedList.Mobi was developed with MobiSiteGalore publishing tools and delivers GenericMedList to mobile users.

End of introductory pricing for MedicalTemplates

2007-09-27T09:20:00.001-05:00

Introductory pricing for MedicalTemplates will end Sept. 30, 2007.

Effective October 1, 2007 the pricing for MedicalTemplates will be -

$150 for an individual practitioner license
$400 for a 3-5 practitioner license
$1000 for a unlimited practitioner license

Generic Medication Discount Database

2007-08-20T09:52:00.001-05:00

We have launched a searchable generic medication discount program list on GenericMedList.Com.

This list can be searched by medication name, and will return discount programs and prices for that generic medication.

Discount programs from Walmart, Target, Publix, and Meijer stores are currently featured in the database.

GenericMedList is a valuable resource healthcare consumers and professionals concerned about the high cost of medications.

MedSpel Web Site

2007-08-09T13:00:00.001-05:00

MedSpel now has its own web site - www.medspel.com

MedSpel is an award winning medical spelling tool for Microsoft Word that was recently updated to be compatible with Windows Vista and Office Vista.

MedSpel adds over 40,000 medical terms to the Microsoft Word spellchecker.

This new addition will mirror the official e-MedTools MedSpel section at this time.

A log in area to download updates is in the works for registered users.

Hospital Follow Up MedicalTemplate Updated 7/16/07

2007-07-16T21:55:00.001-05:00

The hospital follow up MedicalTemplate has been updated with a new layout.

The hospital follow up MedicalTemplate sample can be downloaded from here.

Quality Measures for the Medicare 2007 PQRI Program

2007-07-11T20:02:00.000-05:00

This comprehensive presentation reviews the quality measures that are part of the 2007 Medicare Physician Quality Reporting Initiative (PQRI).

Slideshow Transcript

Slide 1: Centers for Medicare & Medicaid Services 2007 Physician Quality Reporting Initiative (PQRI) Coding for Quality: The Measures Module IV June 13, 2007 1

Slide 2: Disclaimers This presentation was current at the time it was published or uploaded onto the web. Medicare policy changes frequently so links to the source documents have been provided within the document for your reference. This presentation was prepared as a tool to assist providers and is not intended to grant rights or impose obligations. Although every reasonable effort has been made to assure the accuracy of the information within these pages, the ultimate responsibility for the correct submission of claims and response to any remittance advice lies with the provider of services. The Centers for Medicare & Medicaid Services (CMS) employees, agents, and staff make no representation, warranty, or guarantee that this compilation of Medicare information is error-free and will bear no responsibility or liability for the results or consequences of the use of this guide. This publication is a general summary that explains certain aspects of the Medicare Program, but is not a legal document. The official Medicare Program provisions are contained in the relevant laws, regulations, and rulings. 2

Slide 3: Disclaimers The Medicare Learning Network (MLN) is the brand name for official CMS educational products and information for Medicare fee-for-service providers. For additional information visit the Medicare Learning Network’s web page at www.cms.hhs.gov/MLNGenInfo on the CMS website. Current Procedural Terminology (CPT) is copyright 2006 American Medical Association. All Rights Reserved. No fee schedules, basic units, relative values, or related listings are included in CPT. The AMA assumes no liability for the data contained herein. Applicable FARS/DFARS restrictions apply to government use. The International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) is published by the United States Government. A CD-ROM, which may be purchased through the Government Printing Office, is the only official Federal government version of the ICD-9-CM. ICD-9-CM is an official Health Insurance Portability and Accountability Act standard. 3

Slide 4: Overview • PQRI Introduction: Information about PQRI • PQRI Tools: Implementing PQRI • PQRI Principles: Understanding the Measures • PQRI Coding: Examples of Measures • PQRI Readiness: Ensuring Success 4

Slide 5: PQRI Introduction: Value-Based Purchasing • Value-based purchasing is a key mechanism for transforming Medicare from a passive payer to an active purchaser. – Current Medicare Physician Fee Schedule is based on quantity and resources consumed, NOT quality or value of services. • Value = Quality / Cost – Incentives can encourage higher quality and avoidance of unnecessary costs to enhance the value of care. 5

Slide 6: PQRI Introduction: Focus on Quality • PQRI reporting will focus attention on quality of care. – Foundation is evidence-based measures developed by professionals – Measurement enables improvements in care – Reporting is the first step toward pay for performance 6

Slide 7: PRQI Introduction: The Process Visit Documented in Encounter Form Coding & Billing the Medical Record NCH Analysis Contractor National Claims Carrier/MAC History File Confidential Bonus Payment 7 Report Procurement Sensitive 7

Slide 8: PQRI Introduction: Feedback Reports • Confidential Feedback Reports – enable quality improvement at the practice level – include reporting and performance rates by NPI for each TIN. 8

Slide 9: PQRI Introduction: Key Information • Reporting period: Dates of Service between July 1, 2007 through December 31, 2007 • No need to register: just begin reporting • Must be an enrolled Medicare provider (but need not have signed a Medicare participation agreement) • Need to use individual National Provider Identifier (NPI). 9

Slide 10: Coding for Quality: PQRI Tools Implementing PQRI 10

Slide 11: PQRI Tools: Where to Begin • Gather information and educational materials from the PQRI web page: www.cms.hhs.gov/pqri on the CMS website. • Gather information from other sources, such as your professional association, specialty society or the American Medical Association. 11

Slide 12: PQRI Tools: The PQRI Website • www.cms.hhs.gov/pqri – Overview – CMS Sponsored Calls – Statute/Regulations/Program Instructions – Eligible Professionals – Measures/Codes – Reporting – Analysis and Payment – Educational Resources 12

Slide 13: PQRI Tools: The Measure List 13 Procurement Sensitive 13

Slide 14: PQRI Tools: MLN 5640: Coding and Reporting Principles 14 Procurement Sensitive 14

Slide 15: PQRI Tools: Coding for Quality A Handbook for PQRI Participation 15 Procurement Sensitive 15

Slide 16: PQRI Tools: Coding for Quality A Handbook for PQRI Participation • Selecting measures and preparing to report • PQRI coding and reporting principles for the claims based submission of quality data codes • Sample clinical scenarios for each measure, listed by clinical condition/topic, describes successful reporting (and performance where applicable) • PQRI Glossary • 2007 PQRI Code Master • Sample implementation flow chart 16

Slide 17: PQRI Tools: Coding for Quality A Handbook for PQRI Participation Examples of Clinical Conditions/Topics • Clinical Conditions • Clinical Topics – Asthma – Advance Care Planning – Cancer ( Breast, Colon, – Screening for Fall Risk CLL, etc) – Imaging – Chest Pain – Medication – COPD Reconciliation – CAD – Perioperative Care – Depression – Diabetes – GERD 17

Slide 18: PQRI Tools: Measure- specific Data Collection Worksheets • Measure Specific – Measure Description – Worksheet – Coding Specifications 18

Slide 19: PQRI Tools: The Code Master • Excel Spreadsheet – a sequential list of all ICD-9-CM (I9) – CPT ® (CPT4) codes (including CPT II Codes) – CPT II exclusion modifiers that are included in the 2007 PQRI. 19

Slide 20: Coding for Quality: PQRI Principles Understanding the Measures 20

Slide 21: Understanding the Measures: Commonalities • 74 unique measures associated with clinical conditions that are routinely represented on Medicare Fee-for-Service (FFS) claims – ICD-9-CM diagnosis codes – HCPCS codes 21

Slide 22: Understanding the Measures: Scope • The measures address various aspects of quality care – Prevention – Chronic Care Management – Acute Episode of Care Management – Procedural Related Care – Resource Utilization – Care Coordination 22

Slide 23: Understanding the Measures: Construct Clinical action required for reporting and performance ________________________________ Eligible cases for a measure (the eligible patient population associated with the numerator) 23

Slide 24: Understanding the Measures: Construct CPT II Code or Temporary G Code ________________________________ ICD-9-CM and CPT Category I Codes 24

Slide 25: Understanding the Measures: Quality Data Codes Quality-Data Codes translate clinical actions so they can be captured in the administrative claims process 25

Slide 26: Understanding the Measures: Quality Data Codes • Quality-Data Codes can relay that: – The measure requirement was met or – The measure requirement was not met due to documented allowable performance exclusions (i.e., using performance exclusion modifiers) or – The measure requirement was not met and the reason is not documented in the medical record (i.e., using the 8P reporting modifier) 26

Slide 27: Understanding the Measures: The Performance Modifiers • Performance Measure Exclusion Modifiers indicate that an action specified in the measure was not provided due to medical, patient or systems reason(s) documented in the medical record: – 1P- Performance Measure Exclusion Modifier due to Medical Reasons – 2P- Performance Measure Exclusion Modifier used due to Patient Reason – 3P- Performance Measure Exclusion Modifier used due to System Reason • One or more exclusions may be applicable for a given measure. Certain measures have no applicable exclusion modifiers. Refer to the measure specifications to determine the appropriate exclusion modifiers. 27

Slide 28: Understanding the Measures: The Reporting Modifier • Performance Measure Reporting Modifier facilitates reporting a case when the patient is eligible but the action described in a measure is not performed and the reason is not specified or documented – 8P- Performance Measure Reporting Modifier- action not performed, reason not otherwise specified 28

Slide 29: Understanding the Measures: Performance Time Frame • Some measures have a Performance Timeframe related to the clinical action that may be distinct form the reporting frequency. – Perform within 12 months – Most Recent • Clinical test result needs to be obtained, reviewed, reported one time. It need not have been performed during the reporting period. 29

Slide 30: Understanding the Measures: Reporting Frequency • Each measure has a Reporting Frequency requirement for each eligible patient seen during the reporting period – Report one-time only – Report once for each procedure performed – Report for each acute episode 30

Slide 31: Coding for Quality: PQRI Coding Examples Of Measures 31

Slide 32: Coding for Quality • NOTE: The following are examples of draft worksheets that will be made available soon to facilitate PQRI data capture and reporting. • In some cases, the material upon which they are based has changed. Final data worksheets and supporting documents will be available on the CMS PQRI website in advance of July 1, 2007. 32

Slide 33: Coding for Quality: Example #1- Prevention Measure #4 – Screening for Future Fall Risk 33

Slide 34: 34 Procurement Sensitive 34

Slide 37: Coding for Quality: Example #2-Chronic Care Management Measure #5 – Angiotensin Converting Enzyme (ACE) Inhibitor or Angiotensin Receptor Blocker (ARB) Therapy for Left Ventricular Systolic Dysfunction (LVSD) 37 Procurement Sensitive 37

Slide 38: 38 Procurement Sensitive 38

Slide 41: Coding for Quality: Example #3- Acute Episode of Care Management Measure #55 – Electrocardiogram (ECG) Performed for Syncope 41 Procurement Sensitive 41

Slide 42: 42 Procurement Sensitive 42

Slide 45: Coding for Quality: Example #4- Procedural Related Care Measure # 20 – Timing of Antibiotic Prophylaxis – Ordering Physician 45 Procurement Sensitive 45

Slide 46: 46 Procurement Sensitive 46

Slide 50: Coding for Quality: Example #5-Resource Utilization Measure #66 – Appropriate Testing for Children with Pharyngitis 50 Procurement Sensitive 50

Slide 51: 51 Procurement Sensitive 51

Slide 54: Coding for Quality: Example #6- Care Coordination Measure # 47– Advance Care Plan 54 Procurement Sensitive 54

Slide 55: 55 Procurement Sensitive 55

Slide 58: Coding for Quality: PQRI Readiness Ensuring Success 58

Slide 59: PQRI Reporting: Ensuring Success • Eligible professionals interested in testing their billing system and practice readiness prior to July 1 will have an opportunity to do so. • CMS has designated code G8300 as a test code for PQRI reporting for dates of service prior to July 1, 2007. Note that G8300 will become 'Not Valid for Medicare Purposes’ effective for dates of service on and after July 1, 2007. Providers should not submit this code on claims for dates of service on and after July 1. • Simply add the G8300 as a line item on any claims for services prior to July 1, 2007. • Enter “$0.00” or “$0.01” as the line item charge for the test code. This will test the ability of the billing software or clearance house to accept either. 59 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

Slide 60: PQRI Reporting: Ensuring Success • Start reporting early to increase the probability of achieving the 80 percent rate of reporting during the reporting period. • Report on as many measures as possible to increase the likelihood of achieving successful reporting. • Report on as many eligible patients as you can to decrease the probability of being subject to the bonus cap. • Ensure that quality codes are reported on the same claim as the diagnosis or CPT-I codes. 60 Current Procedural Terminology © 2006 American Medical Association. All Rights Reserved.

Slide 61: PQRI Reporting: Ensuring Success • Educational Resources – CMS PQRI website contains all publicly available information at: www.cms.hhs.gov/PQRI • Frequently Asked Questions • PQRI Fact Sheet • Medicare Carrier/Medicare Administrative Contractor (MAC) inquiry management 61