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1、Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMedicalMedical TemplatesTemplatesMaking Medical Documentation Simple and PainlessBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsProblemProblemA familiar lame
2、nt . . .“No matter how much I write in my history and physical exam note, I never seem to document enough to substantiate a high level encounter!”Medical documentation is not about HOW MUCH you write! It is about WHAT you write!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medi
3、cal documentation toolsMedicalTemplatesMedicalTemplates Can Help!Can Help!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsWhat are MedicalTemplates?What are MedicalTemplates?Standardized patient encounter forms using Adobe PDF TechnologyvUse as a paper
4、form OR vComplete form electronicallyBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsMedicalTemplates FeaturesMedicalTemplates FeaturesDocumentation prompters v HCFA 1997 documentation guidelines Quality reminders v Medicare PQRI Checkboxes v Save time
5、v Save energy Fillable Text Boxes v Easy to use v Save time v Save energy Time saved is Money earned!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsThe New Ambulatory Evaluation The New Ambulatory Evaluation Template from MedicalTemplatesTemplate from
6、MedicalTemplatesStill has easy to use check boxes and fillable text boxes! Now with new featuresv ROS with separate “yes” and “no” buttons for ease of documenting “pertinent positive and negative” findings v “Reset” button for each section of ROS v Built in reminders of documentation guidelines for
7、sections of the history and physical exam v Link button for 1997 Guidelines for Evaluation 14:184-92 and FPM October 2003 “How to get all the 99214s you deserve”)Differences in Medicare reimbursement99214 - 99215 = $3099214 - 99213 = $30If you see 30 patients per day you may lose $300 or more per da
8、y!33%(30 patients/day) x $30/patient = $300/dayWorking 5 days/week for 50 weeks, that is a potential loss of $75,000 in just 1 year due to inadequate coding!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsWhat Is The Gain?What Is The Gain?Decreasing bil
9、ling 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 690 patients/year Or, an extra 3 patients/day! WITHOUT THE EXTRA WORK!Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical document
10、ation toolsBenefits of MedicalTemplatesBenefits of MedicalTemplatesq Easy to use q Legible q Fast and simple to complete q Saves dictation and transcription costs q Fast and simple to implement in any practice q Standardizes documentation q Enhances risk management strategies q Reduces the risk of d
11、own coding vWhen documentation is appropriate for billing code Brought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsProfessional, Medical and Legal BenefitsProfessional, Medical and Legal BenefitsLegible, thorough, and standardized documentation is a proven
12、strategy to reduce risk vThorough documentation becomes the standard of care vImproved, thorough documentation can support Audits of Billing codes when correct code is billed for level of documentation Mandatory Quality reporting Pay For Performance Quality Assurance projects Maintenance of Certific
13、ation projects Self evaluation of practice performance ABIM Practice Improvement ModuleBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsA Quick Review of A Quick Review of Medical DocumentationMedical Documentation RequirementsRequirementsBrought to you
14、by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsPatient EncountersPatient EncountersThe 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.Brought
15、to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsKey Components of DocumentationKey Components of DocumentationHistory Exam Medical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time 1997 Guidelines for Evaluation & Management Serv
16、ices http:/www.cms.hhs.gov/MLNProducts/Downloads/MASTER1.pdfKey components in selecting the level of E/M servicesBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsThe HistoryThe HistoryBrought to you by e-Medtools and MedicalTemplatesPhysician designed medical documentation toolsHistory Components and Levels History Components and Levels HPIROSPFSHType of History BriefN/AN/AProblem Focus
