iRVU Is Here

e-MedTools, the people who make MedicalTemplates and E/M Code Check, have created a new smartphone app - iRVU.

iRVU tracks the wRVUs a health care provider generates. Not only will iRVU tally the wRVUs, it will also generate a wRVU/Encounter number.

The total number of wRVUs generated and the number of wRVUs/Encounter are benchmarks used to determine individual productivity, estimate revenue generated, and compare one health care provider's productivity with another.

Virtually every medical practice uses these benchmarks to assess physician productivity and relative value to the practice.

e-MedTools have some awesome products.

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

10 Reasons To Own E/M Code Check

The folks at e-MedTools have created another terrific medical documentation tool!

E/M Code Check is an application for smart phones (iPhone, Android, etc.) that contains important financial data for physicians. This tool not only provides benchmark data from Medicare, such as coding distribution curves and average reimbursement rates, it provides succinct summaries of documentation requirements for coding levels for many types of clinical encounters. E/M Code Check even includes encounter information not found in other medical documentation tools.

The most exciting feature of E/M Code Check is the Personal Productivity Log that tallies all patient encounter codes, then reports the data in a graph format that includes a personalized coding distribution graph, reimbursement, average number work RVUs per encounter, etc.

In today's economy, and with Medicare dropping the reimbursement rates twice in 2010 for sub-specialist physicians, and more cuts to Medicare reimbursement rates planned for December 2010 and January 2011, this tool is indispensable!

10 Reasons to Own EM Code Check

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

Trailblazer Medicare Audit Tool

The folks at e-medtools who create MedicalTemplates, MedSpel and the E and M Audit Tool have created a Trailblazer Medicare Audit Tool. This tool is useful to health care providers in Delaware, Maryland, Virginia and District of Columbia.

Like all their templates, the Trailblazer Medicare Audit Tool is created using a fillable PDF format so that the form can be completed online or printed and completed by hand.

Reimbursement for health care services is complex and confusing. Taking the time to learn and incorporate appropriate medical documentation into every patient encounter note benefits everyone, but is even more critical these days given the severe economic pressures and increased scrutiny by insurance companies.

These Medicare audit tools make great tools for learning the complexities of medical documentation necessary to justify billing levels. When it comes to documentation, if it isn't documented it didn't happen according to medical insurance companies (and lawyers, of course).

Trailblazer Medicare Audit Tool

Medical Documentation: Respiratory Single Organ System Exam

Documentation of the Respiratory Single Organ System Exam

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Single Organ System Exam Respiratory Created by The Lung Doctor Single Organ System Exam Respiratory Comprehensive Level Perform and document ALL elements in the following organ systems Perform and document at least 1 element in each of the following        Constitutional ENT Inspection Neck Respiratory Cardiovascular Gastrointestinal Lymphatic Musculoskeletal Extremities Skin Neurologic Created by The Lung Doctor Single Organ System Exam Respiratory Constitutional Document at least 3 vital signs as follows  Blood Pressure – Sitting OR Standing  Blood Pressure – Lying  Pulse – Rate AND Regularity  Temperature  Height  Weight Note: May be measured and recorded by ancillary staff Created by The Lung Doctor Single Organ System Exam Respiratory Ears, Nose, Mouth, Throat Inspection of nasal mucosa, septum, turbinates Inspection of teeth and gums Examination of oropharynx  Oral mucosa, hard and soft palates, tongue, tonsils, and posterior pharynx Created by The Lung Doctor Single Organ System Exam Respiratory Neck Examination of neck  Masses, overall appearance, symmetry, tracheal position, crepitus Examination of thyroid  Enlargement, tenderness, mass Examination of jugular veins  Distension, a, v or cannon a waves Created by The Lung Doctor Single Organ System Exam Respiratory Respiratory Inspection of chest with notation of symmetry and expansion Assessment of respiratory effort  Intercostal retractions, accessory muscle use, and diaphragmatic movement Percussion of chest  Dullness, flatness, hyperresonance Palpation of chest  Tactile fremitus Auscultation of lungs  Breath sounds, adventitious sounds, rubs Created by The Lung Doctor Single Organ System Exam Respiratory Cardiovascular Auscultation of heart sounds, abnormal sounds and murmurs Examination of peripheral vascular system by observation and palpation  Swelling and varicosities  Pulses, temperature, edema, tenderness Created by The Lung Doctor Single Organ System Exam Respiratory Gastrointestinal (Abdominal) Examination of abdomen with notation of presence or absence of masses or tenderness Examination of liver and spleen Created by The Lung Doctor Single Organ System Exam Respiratory Lymphatic Palpation of lymph nodes  Neck  Groin  Axilla  Other location Note: Exam of at least 2 locations must be documented Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Musculoskeletal Assessment of muscle strength and tone with notation of any atrophy and abnormal movements  Flaccid, cogwheel, spastic Examination of gait and station Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Extremities Inspection and palpation of digits and nails  Clubbing, cyanosis, inflammation, petechiae, ischemia, infections, nodes Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Skin Inspection and/or palpation of skin and subcutaneous tissue  Rashes, lesions, ulcers Created by The Lung Doctor Single Organ System Exam Respiratory Perform and document at least 1 of the following Neurological/Psychiatric Brief assessment of mental status  Include orientation to person, time and place  Include mood and affect – Anxiety, depression, agitation Created by The Lung Doctor

A concise summary of the medical documentation requirements for the respiratory single organ system exam. The documentation requirements for the history and medical decision making components are similar in all exam types, and can be reviewed in the Demystifying Medical Documentation presentation.

Medical Documentation: Level of Service Requirements

Documentation of Level of Service of Medical Encounters

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Documentation of Level of Service of Medical Encounters 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

A concise summary of the medical documentation required to determine the overall level of service for medical encounters based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

Medical Documentation: Medical History

Documentation of the Medical History

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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 Quality Contains 1-3 elements listed Severity Extended Duration Contains ≥ 4 elements Timing 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 Documents responses to the system directly related to the presenting problem Extended Documents positive and negative responses to 2-9 systems related to the problem Complete Documents all positive and negative responses to systems related to the presenting problem AND all other 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 Document at least 1 item from ANY of the 3 areas It must 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

A concise summary of the medical documentation requirements for the medical history based on the 1997 Evaluation and Management Services Guidelines. This is an excerpt of the presentation Demystifying Medical Documentation.

E and M Documentation and Coding Tool: Aqua

This version uses a different color theme, making it easier to view and use the worksheet in a printed format.
This form is also available as a fillable PDF.

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