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E_M Documentation_Training_Audit Tool
E_M Documentation_Training_Audit Tool
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Pdf Summary
The document titled "Evaluation & Management Documentation Training Tool" from National Government Services, Inc. is a comprehensive guide for healthcare providers on how to accurately document patient evaluations and management (E/M) services for compliance and appropriate billing reimbursement. The tool covers multiple sections crucial for E/M documentation:<br /><br />1. **History**:<br /> - **Components**: History of Present Illness (HPI), Review of Systems (ROS), and Past Medical, Family, Social History (PFSH).<br /> - **Classification**: Providers are instructed on how to classify and quantify these data points to determine the type of history—Problem Focused, Expanded Problem Focused, Detailed, or Comprehensive.<br /><br />2. **Examination**:<br /> - **1995 vs. 1997 Rules**: Providers can choose either the 1995 or 1997 documentation guidelines to quantify the examination findings. <br /> - **Body Areas and Organ Systems**: Detailed information on which areas and systems should be examined and documented.<br /><br />3. **Medical Decision Making**:<br /> - **Number of Diagnoses or Treatment Options**: Categorizes problems (e.g., self-limited, established, new) and assigns points to quantify the level of complexity.<br /> - **Amount and Complexity of Data Reviewed**: Metrics for data review, such as laboratory tests and independent visualizations of imaging.<br /> - **Risk of Complications and/or Morbidity or Mortality**: Provides a risk table used as a guide to assess various levels of patient risk and management options, spanning minimal to high complexity.<br /><br />4. **Time**:<br /> - Notes the importance of documenting total time spent with the patient if more than 50% of the encounter involves counseling or coordinating care, allowing time to determine the level of service.<br /><br />5. **Level of Service**:<br /> - **Grids**: Guidelines for determining the level of service (I to V) for various settings including outpatient, emergency room, inpatient, nursing facility, domiciliary, and home care. <br /> - **Criteria**: Specific criteria for each level regarding history, examination, and complexity of medical decision-making.<br /><br />6. **Medical Necessity**:<br /> - Emphasizes that the medical necessity of the service is the overarching criterion for billing and payment, rather than the sheer volume of documentation.<br /><br />In summary, this document is an instructional tool aimed at ensuring that healthcare providers meet required documentation standards to justify the levels of service billed to Medicare, enhancing accuracy and compliance with federal regulations.
Keywords
E/M documentation
patient evaluations
billing reimbursement
history components
examination guidelines
medical decision making
documentation time
level of service
medical necessity
compliance
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