Medical Documentation, Billing and Coding

Medical documentation, billing and coding requires knowledge of complex, changing rules. Thank goodness for medical documentation, billing and coding experts who can be so darn helpful!

Thank goodness, too, for point of care tools that make medical documentation and coding much easier to understand and implement, and save time and money!

A couple of these tools deserve mentioning again.

E/M Code Check is such an exciting smartphone application! It has a concise, easy to follow format. Each page is really information packed, and the buttons to transition to the next page are very easy to use, unlike some other smartphone apps.

E/M Code Check incorporates great graphics, providing a great deal of information (pictures are worth a thousand words!) on personal documentation and coding habits. The feedback this tool provides is terrific, and it will help most anyone to learn where they need to improve.

Like some other companies, E/M Code Check provides a free version, making money by inserting ads, but the $34.99 version is worth every cent!

E/M Code Check provides Medicare reimbursement rates (based on national averages), tallies them based on the encounter types entered, and graphs personal coding distribution levels!

E/M Code Check also reinforces the use of MedicalTemplates for documentation of patient encounters. MedicalTemplates are terrific tools for prompting health care providers to document a complete history and physical exam. Sometimes the situation or conversations in patient encounters can derail a train of thought. Who hasn't had to return to a patient room to ask about some missing piece of the social history? With MedicalTemplates a physician can be confident that they are consistently documenting a thorough patient encounter note. Best of all, thorough documentation using MedicalTemplates saves time. Most aspects of the patient encounter can be documented with a simple check mark, but there is ample space to write personal notes.

If you haven't checked out these products, go to e-MedTools.com

MedicalTemplates' Outpatient Pulmonary Clinic Evaluation

The folks at e-medtools who create MedicalTemplates have updated their Outpatient Pulmonary Clinic Evaluation for new patient evaluations. This new template looks much better than the previous version! It also appears to have quite a few more convenient features!

The ROS (Review of Systems) has been updated to reflect the ROS on their other templates. Having a ROS with space to document both "yes" and "no" responses makes a great deal of sense medically and legally! The PMH (Past Medical History) is much cleaner, more straightforward, and limited to the most common diagnoses. They have left room, though, for addition of a tailored set of diagnoses, such as specific pulmonary diseases that are not very common. There is also a very nice list of common surgeries that really save on documentation time and effort! Prompters for significant Social History information like ADLs (Activities of Daily Living) and behavioral and occupational risk factors are extraordinarily important to most patients seen by a pulmonologist, but are often excluded from standard medical templates.

The exam is quite extensive with relevant negative and positive findings that, again, stand to save pulmonologists a great deal of time and effort. Time is money, and quality of life is extremely important!

There is significantly more space in the Impression and Plan section, which is a great improvement over the previous version. Space for adequate discussion of the differential diagnoses and treatment options was previously limited.

MedicalTemplates is doing a great job! Documentation of the patient encounter is complex and confusing! There are so many rules that differ with each payor, and often change from year to year, that it makes sense to take a more consistent approach to documenting every patient encounter!

Pulmonary Clinic History and Physical