ProblemAfamiliarlament... “NomatterhowmuchIwriteinmyhistoryandphysicalexamnote,Ineverseemtodocumentenoughtosubstantiateahighlevelencounter!”MedicaldocumentationisnotaboutHOWMUCHyouwrite!ItisaboutWHATyouwrite!MedicalTemplatesCanHelp!WhatareMedicalTemplates?pleteformelectronicallyMedicalTemplatesFeaturesDocumentationpromptersHCFA1997documentationguidelinesQualityremindersMedicarePQRICheckboxesSavetimeSaveenergyFillableTextBoxesEasytouseSavetimeSaveenergyTimesavedisMoneyearned!TheNewAmbulatoryEvaluationTemplatefromMedicalTemplatesStillhaseasytousecheckboxesandfillabletextboxes!NowwithnewfeaturesROSwithseparate“yes”and“no”buttonsforeaseofdocumenting“pertinentpositiveandnegative”findings“Reset”buttonforeachsectionofROSBuiltinremindersofdocumentationguidelinesforsectionsofthehistoryandphysicalexamLinkbuttonfor1997GuidelinesforEvaluation&ManagementServicesDocumentationremindersofrequirementsfortherelevantsectionLinktothe1997GuidelinesforEvaluation&ManagementServicesSeparate“yes”and“no”optionsfordocumentingpertinentpositiveandnegativeresponsesResetbuttonsManyPhysiciansUnderCode!Mosthealthcareprovidersdomoreworkthantheirdocumentationsupports!And,asthesayinggoes,ifitisn’tdocumented,itdidn’thappen!HowMuchIsAtStake?Fact 33-52%ofpatientencountersareUNDERcoded(JABFP2001;14:184-92andFPMOctober2003“Howtogetallthe99214syoudeserve”)DifferencesinMedicarereimbursement99214->99215=$3099214->99213=$30Ifyousee30patientsperdayyoumaylose$300ormoreperday![33%(30patients/day)x$30/patient=$300/day]Working5days/weekfor50weeks,thatisapotentiallossof$75,000injust1yearduetoinadequatecoding!!!WhatIsTheGain?Decreasingbillingandcodingerrorsbyjust50%couldmeananincreaseofnearly$40,000peryearinpracticerevenues!Theequivalentofseeinganadditional690patients/yearOr,anextra3patients/day!WITHOUTTHEEXTRAWORK!pleteSavesdictationandtranscriptioncostsFastandsimpletoimplementinanypracticeStandardizesdocumentationEnhancesriskmanagementstrategiesReducestheriskofdowncodingWhendocumentationisappropriateforbillingcode
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