Coding and Documentation in Practice

Size: px
Start display at page:

Download "Coding and Documentation in Practice"

Transcription

1 Coding and Documentation in Practice Great Exam Documentation By: Kathy Mills Chang Kathy Mills Chang is a Certified Medical Compliance Expert, Reimbursement Consultant, Medicare Specialist, and a Documentation Authority celebrating 28 years of service to the chiropractic profession. Evaluation and Management: Detailed, comprehensive, and qualitative documentation of patient examination and management services provides a means for accurate coding and identification of billable services provided. 7 Components of EM: History Examination Clinical Decision Making Counseling Coordination of Care Nature of Presenting Problem Time (least important) Pages: 1 of 9

2 3Factors of EM Codes: Place of Service (hospital, office, etc.) Type of Service (consultation, typical office visit, preventative) Patient Status (new or existing patient) Bad Habits: Habitually over or under coding Reporting for reimbursement rather than medical necessity Consistently billing the same level of service Patterns and repetition in documentation Consistent non-compliance is a serious act and ignorance is not a valid excuse. Stay Compliant: Learn the E/M documentation guidelines. Understand the 3 key components that are used in selecting the level of service. (History, Examination, Clinical Decision Making) Specialty Examination Guidelines: Allows for 10 single system evaluations There are 1995 (whole body) and 1997 Medicare guidelines. Chiropractors can use whatever set of guidelines is more beneficial to their practice. Pages: 2 of 9

3 The 1997 Medicare Guidelines are more beneficial for chiropractors to follow because they allow for musculoskeletal standards that are the primary form of treatment in the typical chiropractic office. Be sure the insurance carrier is aware of the guidelines your office is following. Scoring Your Examination: The guidelines are bullet oriented You must identify each bullet you plan to count in your examination record Skin and Musculoskeletal documentation allow multiple bullets per section 1) Head and Neck 2) Spine, Ribs and Pelvis or Trunk 3-6) are the extremities each counted separately Body Areas Recognized by CMS: Constitutional (e.g. vital signs, general appearance) Eyes Ears, Nose, Mouth, and Throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurologic Psychiatric Hematologic/ Lymphatic/ Immunologic Guideline Tidbits: Pages: 3 of 9

4 Specific abnormal and relevant negative findings of the examination of the affected or symptomatic body area(s) or organ system(s) should be documented. A notation of abnormal without elaboration is insufficient. Abnormal or unexpected findings of the examination of the unaffected or asymptomatic body area(s) or organ system(s) should be described. Follow Your Guide. Cardiovascular Examination: Examination of peripheral vascular system by observation (e.g. swelling, vericosities) and palpation (e.g. pulses, temperature, edema, tenderness) Lymphatic Examination: Palpation of lymph nodes in the neck, axillae, groin, and/or other location. Notation of any abnormalities or when within normal limits. Extremity Examination: Extremities are covered as part of the Musculoskeletal examination. Extremities are not required, but may apply on a patient by patient basis. Skin Examination: Inspection and/or palpation of skin and subcutaneous tissue (e.g. scars, rashes, lesions, café-au-lait spots, ulcers) in four of the following 6 areas. Pages: 4 of 9

5 Include dermatome inspection. Head and Neck Trunk Right upper extremity Left upper extremity Right lower extremity Left lower extremity Pages: 5 of 9

6 Neurological Examination: Test Coordination- (e.g. finger/ nose, heel/knee/shin, rapid alternating movements in the upper and lower extremities, evaluation of fine motor control and coordination in young people) Examination of Deep Tendon Reflexes and/or Nerve Stretch Test with notation of Pathological Reflexes- (e.g. Babinski) Examination of Sensation- (e.g. touch, pin, vibration, proprioception) Orientation to Time, Place, and Person Mood and Affect- (e.g. depression, anxiety, agitation) Mood, Affect, and Appearance: Appearance - How does the patient look? (Neat, Groomed, Attention to Detail) Level of Alertness - Conscious? If not, can they be aroused? Can they focus? (Attention Span) Speech - Normal tone, Volume, and Quantity? Behavior - Pleasant, Cooperative, Agitated? Orientation - Awareness of environment? (Who, What, Where, When) Mood - (Happy, Sad, Depressed, Angry) Is it appropriate for the situation? Affect - How do they appear to you? (Your observations, are they appropriate?) Constitutional Exam Measurement of any three of the following seven vital signs: Pages: 6 of 9

7 sitting or standing blood pressure supine blood pressure pulse rate and regularity respiration temperature height weight (May be measured and recorded by ancillary staff) General appearance of patient (e.g. development, nutrition, body habitus, deformities, attention to grooming) Musculoskeletal Examination: This is the primary and most significant portion of the exam you will most typically perform. Although you may always do these things, they might not be documented in a particular manner. Historical clues when evaluating any joint related complaint: (Functional impairments, not pain, dictates Medical Necessity) What is the functional limitation? Symptoms within a single region or affecting multiple joints? Acute or slowly progressive? Mechanism of injury? Prior history of problems in this area? Systemic symptoms? Bullet Points: Pages: 7 of 9

8 Examination of gait and station- (identify gross abnormalities of gait indicating a neurological disorder, speed, balance, heel to toe walking, pain limitations, Romberg Test for the vestibular system) General Musculoskeletal- Examination of joints, bones, and muscles/tendons of 4 of the following 6 areas. o Head and Neck o Trunk o Right upper extremity o Left upper extremity o Right lower extremity o Left lower extremity PART Documentation: Inspection, percussion and/or palpation with notation of any misalignment, asymmetry, crepitation, defects, tenderness, masses or diffusions. (P and A) Assessment of range of motion with notation of any pain (e.g. straight leg raising), crepitation or contracture. (R) Assessment of stability with notation of any dislocation (luxation), subluxation or laxity Assessment of muscle strength and tone (e.g. flaccid, cog wheel, spastic) with notation of any atrophy or abnormal movements. (T) Scoring the Examination: Problem Focused = 1-5 bullet points Expanded = 6-11 bullet points Detailed = 12 or more bullet points (Typical chiropractic new patient exam) Comprehensive = Every bullet point Pages: 8 of 9

9 Code Selection: 3 of 3 must meet of exceed Code History Examination CDM (decision making) Problem Focused Problem Focused Straight Forward Expanded Expanded Straight Forward Detailed Detailed Low Comprehensive Comprehensive Moderate Comprehensive Comprehensive High Pages: 9 of 9

E/M Learning Tips INTRODUCTION TO EVALUATION. Introduction to Evaluation and Management (E/M) Coding for the Child and Adolescent Psychiatrist

E/M Learning Tips INTRODUCTION TO EVALUATION. Introduction to Evaluation and Management (E/M) Coding for the Child and Adolescent Psychiatrist INTRODUCTION TO EVALUATION AND MANAGEMENT (E/M) CODING FOR THE CHILD AND ADOLESCENT PSYCHIATRIST Benjamin Shain, MD, PhD David Berland, MD Sherry Barron-Seabrook, MD Copyright 2012 by the American Academy

More information

1997 Documentation Guidelines for Evaluation and Management Services

1997 Documentation Guidelines for Evaluation and Management Services 1997 Documentation Guidelines for Evaluation and Management Services TABLE OF CONTENTS Introduction... 2 What Is Documentation and Why Is it Important?... 2 What Do Payers Want and Why?... 2 General Principles

More information

American Chiropractic Association. Commentary on Centers for Medicare and Medicaid Services (CMS)/PART. Clinical Documentation Guidelines

American Chiropractic Association. Commentary on Centers for Medicare and Medicaid Services (CMS)/PART. Clinical Documentation Guidelines American Chiropractic Association Commentary on Centers for Medicare and Medicaid Services (CMS)/PART Clinical Documentation Guidelines DISCLAIMER The American Chiropractic Association provides this commentary

More information

MOLLOY COLLEGE DIVISION OF NURSING NURSE PRACTITIONER PROGRAMS. Study Guide for the Basic Physical Assessment Exam

MOLLOY COLLEGE DIVISION OF NURSING NURSE PRACTITIONER PROGRAMS. Study Guide for the Basic Physical Assessment Exam DIVISION OF NURSING S Study Guide for the Basic Physical Assessment Exam Questions will be based on following chapters in, Bickley, L.S. (2009). (10 th ed). Bates guide to physical examination and history

More information

TABLE OF CONTENTS. Coding for Procedures - Handout 71 ICD-9-CM Coding - Handout 97. Non-Physician Providers 116

TABLE OF CONTENTS. Coding for Procedures - Handout 71 ICD-9-CM Coding - Handout 97. Non-Physician Providers 116 TABLE OF CONTENTS Page(s) Evaluation and Management Services 2 A. History of Present Illness 3 B. Review of Systems 5 C. Past, Family and Social History 8 D. Physical Examination 1. 1995 Examination 10

More information

General Medical Examination

General Medical Examination General Medical Examination Name: Date of Exam: Place of Exam: SSN: C-number: Narrative: This is a comprehensive base-line or screening examination for all body systems, not just specific conditions claimed

More information

MRADL: Mobility Related Activities of Daily Living 1

MRADL: Mobility Related Activities of Daily Living 1 Note: Text in red italics represents additional text inserted and striking represents text deletion from last posted version Suggested Electronic Clinical Template Elements of a Progress Note Documenting

More information

OVERALL PERFORMANCE. Pediatrics In-Training History and Physical Examination (HPE) Assessment

OVERALL PERFORMANCE. Pediatrics In-Training History and Physical Examination (HPE) Assessment OVERALL PERFORMANCE Pediatrics In-Training History and Physical Examination (HPE) Assessment Name: University: This resident completed the standardized assessment of history -taking, physical examination

More information

Coding for the Internist: The Basics

Coding for the Internist: The Basics Coding for the Internist: The Basics Evaluation and management is the most important part of the practice for an internist and coding for these visits can have an important effect for the bottom line of

More information

Spinal Cord Injury Education. An Overview for Patients, Families, and Caregivers

Spinal Cord Injury Education. An Overview for Patients, Families, and Caregivers Spinal Cord Injury Education An Overview for Patients, Families, and Caregivers Spinal Cord Anatomy A major component of the Central Nervous System (CNS) It is 15 to 16 inches long, and weighs 1 to 2 ounces

More information

Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas

Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas Billing and Coding in Neurology and Headache Stuart B Black MD, FAAN Chief of Neurology Co-Medical Director: Neuroscience Center Baylor University Medical Center at Dallas CPT Codes vs. ICD Codes Category

More information

E&M Coding- It s All About The Documentation

E&M Coding- It s All About The Documentation E&M Coding- It s All About The Documentation Presented for Anthem Blue Cross and Blue Shield By: Penny Osmon, BA, CPC Coding & Reimbursement Educator WI Medical Society Wisconsin Medical Society, Copyright

More information

PHYSICAL EXAMINATION OF THE FOOT AND ANKLE

PHYSICAL EXAMINATION OF THE FOOT AND ANKLE PHYSICAL EXAMINATION OF THE FOOT AND ANKLE Presenter Dr. Richard Coughlin AOFAS Lecture Series OBJECTIVES 1. ASSESS 2. DIAGNOSE 3. TREAT HISTORY TAKING Take a HISTORY What is the patient s chief complaint?

More information

38 Assisting with a General Physical Examination

38 Assisting with a General Physical Examination Learning Outcomes 38-2 38.1 Identify the purpose of a general physical. CHAPTER 38 Assisting with a General Physical Examination 38.2 Describe the role of the medical assistant in a general physical. 38.3

More information

Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario

Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario Page 1 Closed Automobile Insurance Third Party Liability Bodily Injury Claim Study in Ontario Injury Descriptions Developed from Newfoundland claim study injury definitions No injury Death Psychological

More information

Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone

Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone DEMOGRAPHIC INFORMATION Full name DOB Age Address Email Phone numbers (H) (W) (C) Emergency contact Phone CARE INFORMATION Primary care physician: Address Phone Fax Referring physician: Specialty Address

More information

A GUIDE TO EVALUATION & MANAGEMENT CODING AND DOCUMENTATION

A GUIDE TO EVALUATION & MANAGEMENT CODING AND DOCUMENTATION A GUIDE TO EVALUATION & MANAGEMENT CODING AND DOCUMENTATION Produced by ConnectiCare, Inc. in conjunction with its affiliate Group Health Incorporated TABLE OF CONTENTS Summary and Overview...Page 3 Part

More information

TABLE OF CONTENTS CPT

TABLE OF CONTENTS CPT TABLE OF CONTENTS CPT Coding Basics...1 National Correct Coding Initiative Edits...1 How to Use NCCI Edits...2 Evaluation and Management...3 Integumentary System... 20 Debridement... 20 Surgery/Musculoskeletal...

More information

Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915

Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915 Gilbert Varela, M.D., Inc 5232 E. Beverly Boulevard Los Angeles, California 90022 Phone: (323) 724-6911 Fax: (323) 724-6915 September 10, 2007 Law offices of xxxxxxxxx Santa Monica, CA 90405 REGARDING:

More information

Current Procedural Terminology (CPT) Code Changes for 2013

Current Procedural Terminology (CPT) Code Changes for 2013 Current Procedural Terminology (CPT) Code Changes for 2013 For 2013 there have been major changes to the codes in the Psychiatry section of the AMA s Current Procedural Terminology, the codes that must

More information

Therapeutic Canine Massage

Therapeutic Canine Massage Meet our Certified Canine Massage Therapist, Stevi Quick After years of competitive grooming and handling several breeds in conformation, I became interested in training and competing with my dogs in the

More information

Provider Training Series The Search for Compliance. Outpatient Psychiatric Services February 25, 2014 Melissa Hooks, Director of Program Integrity

Provider Training Series The Search for Compliance. Outpatient Psychiatric Services February 25, 2014 Melissa Hooks, Director of Program Integrity Provider Training Series The Search for Compliance Outpatient Psychiatric Services February 25, 2014 Melissa Hooks, Director of Program Integrity Outpatient Psychiatric Services Psychotherapy: Individual,

More information

Emory Eye Center New Patient Questionnaire

Emory Eye Center New Patient Questionnaire Patient Name: Date: Current Address: Current Phone: Date of Birth: Primary Care Physician: Referring Physician: (First & Last Name) (First & Last Name) Pharmacy Name: Phone #: ( ) Please answer all questions

More information

Evaluation & Management. Guidelines. Presented by: Kristi A. Gutierrez CCS-P, CPC, CEMC

Evaluation & Management. Guidelines. Presented by: Kristi A. Gutierrez CCS-P, CPC, CEMC Evaluation & Management Documentation and Coding Guidelines Presented by: Kristi A. Gutierrez CCS-P, CPC, CEMC Objectives Participants will gain a working knowledge of Medicare s 1995 Evaluation & Management

More information

Massachusetts Department of Transitional Assistance EAEDC Medical Report

Massachusetts Department of Transitional Assistance EAEDC Medical Report PATIENT INFORMATION Last Name / / Date of Birth First Name - - Social Security Number Address (Street, City, State, Zip Code) ( ) Telephone Number Massachusetts Department of Transitional Assistance General

More information

Cerebral Palsy. 1995-2014, The Patient Education Institute, Inc. www.x-plain.com nr200105 Last reviewed: 06/17/2014 1

Cerebral Palsy. 1995-2014, The Patient Education Institute, Inc. www.x-plain.com nr200105 Last reviewed: 06/17/2014 1 Cerebral Palsy Introduction Cerebral palsy, or CP, can cause serious neurological symptoms in children. Thousands of children are diagnosed with cerebral palsy every year. This reference summary explains

More information

Dallas Neurosurgical and Spine Associates, P.A Patient Health History

Dallas Neurosurgical and Spine Associates, P.A Patient Health History Dallas Neurosurgical and Spine Associates, P.A Patient Health History DOB: Date: Reason for your visit (Chief complaint): Past Medical History Please check corresponding box if you have ever had any of

More information

Cerebral Palsy. In order to function, the brain needs a continuous supply of oxygen.

Cerebral Palsy. In order to function, the brain needs a continuous supply of oxygen. Cerebral Palsy Introduction Cerebral palsy, or CP, can cause serious neurological symptoms in children. Up to 5000 children in the United States are diagnosed with cerebral palsy every year. This reference

More information

E/M and Psychotherapy Coding Algorithm

E/M and Psychotherapy Coding Algorithm Inpatient PHP Outpatient E/M and Psychotherapy Coding Algorithm CPT five-digit codes, descriptions, and other data only are copyright 2012 by the American Medical Association (AMA). All Rights Reserved.

More information

C CS. California Children Services Alameda County

C CS. California Children Services Alameda County C CS California Children Services Alameda County The California Children Services (CCS) Program strives to assure access to medical services essential to the health and well-being of children with catastrophic

More information

Workbook STD Clinic Billing Coding Evaluation & Management Visits

Workbook STD Clinic Billing Coding Evaluation & Management Visits Workbook STD Clinic Billing Coding Evaluation & Management Visits Developed by the University of Rochester Center for Health & Behavioral Training Capacity Building Assistance (CBA) Adapted from 1997 CMS

More information

Nursing. Management of Spinal Trauma. Content. Objectives. Objectives

Nursing. Management of Spinal Trauma. Content. Objectives. Objectives 7 cervical vertebrae Content 12 thoracic vertebrae Nursing 5 sacral vertebrae Management of Spinal Trauma Kwai Fung Betty Siu Ward Manager O&T Dept TKOH Date : 22nd April 2007 5 lumbar vertebrae 4 coccygeal

More information

UTILIZING STRAPPING AND TAPING CODES FOR HEALTH CARE REIMBURSEMENT:

UTILIZING STRAPPING AND TAPING CODES FOR HEALTH CARE REIMBURSEMENT: UTILIZING STRAPPING AND TAPING CODES FOR HEALTH CARE REIMBURSEMENT: A GUIDE TO BILLING FOR SPIDERTECH PRE-CUT APPLICATIONS AND TAPE Billing and coding taping and strapping services can be a complex issue.

More information

Certified Athletic trainers should follow a 10-step process of evaluation for orthopedic injuries, which includes but is not limited to:

Certified Athletic trainers should follow a 10-step process of evaluation for orthopedic injuries, which includes but is not limited to: Acute Care Policy Acute Care Policy and Procedures Athletic training students within Winona State University s Athletic Training Education Program have the opportunity to evaluate acute athletic injuries

More information

Medical reference Medical guideline Patient factors Provider factors Environment/system factors. Conduct medical encounter

Medical reference Medical guideline Patient factors Provider factors Environment/system factors. Conduct medical encounter Used At: Author: Ken Funk, Mylie Tong, James Bau Date: 6/23/2011 Time: 21:35:03 Medical guideline Patient factors factors Environment/system factors New/returning patient Patient medical records Existing

More information

E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.)

E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.) E/M LEVEL WORKSHEET STEP 1 : IDENTIFY THE CATEGORY AND SUBCATEGORY OF SERVICE Carefully read the documentation. Using the Table of Contents, identify the appropriate category/subcategory. Category Subcategory

More information

Medicaid Disability Manual

Medicaid Disability Manual Part B The following sections apply to individuals under age 18. If the criteria in Part B do not apply, Part A criteria may be used when those criteria give appropriate consideration to the effects of

More information

E/M Components EVALUATION AND MANAGEMENT (E/M) CODING FOR CHILD AND ADOLESCENT PSYCHIATRIC OUTPATIENTS OVERVIEW

E/M Components EVALUATION AND MANAGEMENT (E/M) CODING FOR CHILD AND ADOLESCENT PSYCHIATRIC OUTPATIENTS OVERVIEW EVALUATION AND MANAGEMENT (E/M) CODING FOR CHILD AND ADOLESCENT PSYCHIATRIC OUTPATIENTS Benjamin Shain, MD, PhD David Berland, MD Sherry Barron-Seabrook, MD Copyright 2012 by the American Academy of Child

More information

(For use with 1995 and 1997 CMS Documentation Guidelines for Evaluation & Management Coding )

(For use with 1995 and 1997 CMS Documentation Guidelines for Evaluation & Management Coding ) Appendix I: E/M Codebuilder (For use with 1995 and 1997 CMS Documentation Guidelines for Evaluation & Management Coding ) Introduction The evaluation and management (E/M) code reported to a third-party

More information

2014 E&M Oncology Documentation & Coding Basics Working Smarter, Not Harder!

2014 E&M Oncology Documentation & Coding Basics Working Smarter, Not Harder! 2014 E&M Oncology Documentation & Coding Basics Working Smarter, Not Harder! West Virginia Oncology Society October 2, 2014 This presentation is offered as an educational tool. E&M Consulting Inc. does

More information

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only)

NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) PAGE 1 NEURO-OPHTHALMIC QUESTIONNAIRE NAME: AGE: DATE OF EXAM: CHART #: (Office Use Only) 1. What is the main problem that you are having? (If additional space is required, please use the back of this

More information

Application for a Medical Impairment Rating (MIR)

Application for a Medical Impairment Rating (MIR) STATE OF TENNESSEE DEPARTMENT OF LABOR AND WORKFORCE DEVELOPMENT Workers Compensation Division Medical Impairment Rating Program 220 French Landing Drive Nashville, TN 37243-1002 Phone (615) 253-1613 Fax

More information

Practical E/M Audit Form: Established Outpatient Visit (p.1)

Practical E/M Audit Form: Established Outpatient Visit (p.1) Patient: Name: Chart #: Date of visit: / / Reviewer: Date of review: / / Medical History Review Select the level corresponding to lowest of the components PFSH ROS HPI Level of History 5 2 elements 0 or

More information

Whiplash Associated Disorder

Whiplash Associated Disorder Whiplash Associated Disorder Bourassa & Associates Rehabilitation Centre What is Whiplash? Whiplash is a non-medical term used to describe neck pain following hyperflexion or hyperextension of the tissues

More information

DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS

DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS DENVER CHIROPRACTIC CENTER GLENN D. HYMAN, DC, CSCS Are you in the right place? Please read this before proceeding with paperwork: At Denver Chiropractic Center, we specialize in treating muscles with

More information

Traumatic injuries SPINAL CORD. Causes of Traumatic SCI SYMPTOMS. Spinal Cord trauma can be caused by:

Traumatic injuries SPINAL CORD. Causes of Traumatic SCI SYMPTOMS. Spinal Cord trauma can be caused by: Traumatic injuries SPINAL CORD Jennie Trkulja RN, BScN, ENC (c) Causes of Traumatic SCI Spinal Cord trauma can be caused by: MVC (most injuries) Gunshots Falls Stabbings Assaults Industrial accidents Sports

More information

The Anatomy of Spinal Cord Injury (SCI)

The Anatomy of Spinal Cord Injury (SCI) The Anatomy of Spinal Cord Injury (SCI) What is the Spinal Cord? The spinal cord is that part of your central nervous system that transmits messages between your brain and your body. The spinal cord has

More information

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label)

PATIENT HEALTH QUESTIONNAIRE Radiation Oncology (Patient Label) REVIEWED DATE / INITIALS SAFETY: Are you at risk for falls? Do you have a Pacemaker? Females; Is there a possibility you may be pregnant? ALLERGIES: Do you have any allergies to medications? If, please

More information

Chiropractor Compliance Summary Documentation Compliance Criteria for Chiropractic Claims Submitted to the Funds

Chiropractor Compliance Summary Documentation Compliance Criteria for Chiropractic Claims Submitted to the Funds Chiropractor Compliance Summary Documentation Compliance Criteria for Chiropractic Claims Submitted to the Funds Date: April 23, 2012 Source Information: Medicare Policy Purpose The United Mine Workers

More information

HOW TO CHECK YOUR LYMPH NODES

HOW TO CHECK YOUR LYMPH NODES HOW TO CHECK YOUR LYMPH NODES What are the aims of this leaflet? This leaflet has been written to help you to understand more about how to check your lymph nodes yourself. It tells you why you should be

More information

THE RELATIONSHIP BETWEEN POSTURE AND HEALTH

THE RELATIONSHIP BETWEEN POSTURE AND HEALTH THE RELATIONSHIP BETWEEN POSTURE AND HEALTH Roger Sperry, Ph.D. (Nobel Prize in Physiology or Medicine 1981) discovered that 90% of the brain's activity is used to balance your body within the gravitational

More information

Screening Examination of the Lower Extremities BUY THIS BOOK! Lower Extremity Screening Exam

Screening Examination of the Lower Extremities BUY THIS BOOK! Lower Extremity Screening Exam Screening Examination of the Lower Extremities Melvyn Harrington, MD Department of Orthopaedic Surgery & Rehabilitation Loyola University Medical Center BUY THIS BOOK! Essentials of Musculoskeletal Care

More information

Maximizing Third Party Reimbursement Through Enhanced Medical Documentation and Coding. Installment One of the Webinar Series

Maximizing Third Party Reimbursement Through Enhanced Medical Documentation and Coding. Installment One of the Webinar Series Maximizing Third Party Reimbursement Through Enhanced Medical Documentation and Coding Installment One of the Webinar Series Provides education and capacity building services to a variety of individuals

More information

Evaluating muscle injuries and residuals of shell fragment and gunshot wounds

Evaluating muscle injuries and residuals of shell fragment and gunshot wounds Evaluating muscle injuries and residuals of shell fragment and gunshot wounds Training conducted by: Michael Fishman and Sandrine Fisher 1 Objectives To become familiar with the application of the rating

More information

PATIENT HISTORY FORM

PATIENT HISTORY FORM PATIENT HISTORY FORM If you are new to the office, have not been seen in over one (1) year, or are returning for a new problem, please complete this form in full. If there have been any changes since your

More information

6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S.

6/3/2011. High Prevalence and Incidence. Low back pain is 5 th most common reason for all physician office visits in the U.S. High Prevalence and Incidence Prevalence 85% of Americans will experience low back pain at some time in their life. Incidence 5% annual Timothy C. Shen, M.D. Physical Medicine and Rehabilitation Sub-specialty

More information

Patient Progress Note & Dictation Standard

Patient Progress Note & Dictation Standard Objective: The patient progress note serves as a basis for planning patient care, documenting communication between the health care provider and any other health professional contributing to the patient's

More information

Life Insurance Application Form

Life Insurance Application Form Life Insurance Application Form INSTRUCTION To be completed by all applicants PERSONAL DETAILS Surname First name Middle name Sex Female Male Marital status (please tick) Single Married Other Current residential

More information

Self- Lymphatic Massage for Arm, Breast or Trunk Lymphedema

Self- Lymphatic Massage for Arm, Breast or Trunk Lymphedema Self- Lymphatic Massage for Arm, Breast or Trunk Lymphedema Patient Education Improving health through education The lymphatic system is part of our circulatory system. It helps balance the fluids of our

More information

Cervical Spine. New Patient Form

Cervical Spine. New Patient Form Cervical Spine New Patient Form Please mark the painful areas on the pictures below Use the following marks: stabbing pain ooo burning pain +++ aching pain pins and needles = = = numbness Right Right Right

More information

Rehabilitation Documentation and Proper Coding Guidelines

Rehabilitation Documentation and Proper Coding Guidelines Rehabilitation Documentation and Proper Coding Guidelines Purpose: 1) Develop a guide for doctors in South Dakota to follow when performing reviews on rehabilitation cases. 2) Provide doctors in South

More information

MUSCULOSKELETAL DISORDERS IN SONOGRAPHERS: ARE WE DOING ENOUGH?

MUSCULOSKELETAL DISORDERS IN SONOGRAPHERS: ARE WE DOING ENOUGH? MUSCULOSKELETAL DISORDERS IN SONOGRAPHERS: ARE WE DOING ENOUGH? Many terms are used to refer to work related injuries among sonographers. Musculosketetal injury (MSI) Repetitive motion injury (RMI) Repetitive

More information

MOUNT SAINT MARY COLLEGE Division of Nursing Newburgh, New York COURSE SYLLABUS

MOUNT SAINT MARY COLLEGE Division of Nursing Newburgh, New York COURSE SYLLABUS MOUNT SAINT MARY COLLEGE Division of Nursing Newburgh, New York NUR 2043 Physical Assessment Fall 2006 Accelerated Session D1 COURSE SYLLABUS Course Description This course focuses on the collection, organization,

More information

Coding for Physician/Provider Services: Understanding Key Documentation Issues

Coding for Physician/Provider Services: Understanding Key Documentation Issues Coding for Physician/Provider Services: Understanding Key Documentation Issues Presented by Deborah Holzmark, RN, MBA, CPHQ, MCS-P, CMPE Dixon Hughes PLLC (828) 236-5794 dholzmark@dixon-hughes.com Agenda

More information

A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH)

A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH) A Patient s Guide to Diffuse Idiopathic Skeletal Hyperostosis (DISH) Introduction Diffuse Idiopathic Skeletal Hyperostosis (DISH) is a phenomenon that more commonly affects older males. It is associated

More information

Transmittal 55 Date: MAY 5, 2006. SUBJECT: Changes Conforming to CR3648 for Therapy Services

Transmittal 55 Date: MAY 5, 2006. SUBJECT: Changes Conforming to CR3648 for Therapy Services CMS Manual System Pub 100-03 Medicare National Coverage Determinations Department of Health & Human Services (DHHS) Centers for Medicare & Medicaid Services (CMS) Transmittal 55 Date: MAY 5, 2006 Change

More information

Codes and Documentation for Evaluation and Management Services

Codes and Documentation for Evaluation and Management Services 4 Codes and Documentation for Evaluation and Management Services The evaluation and management (E/M) codes were introduced in the 1992 update to the fourth edition of Physicians Current Procedural Terminology

More information

The type of cancer Your specific treatment Your pre training levels before diagnose (your current strength and fitness levels)

The type of cancer Your specific treatment Your pre training levels before diagnose (your current strength and fitness levels) Exercise and Breast Cancer: Things you can do! Cancer within the fire service is one of the most dangerous threats to our firefighter s health & wellness. According to the latest studies firefighters are

More information

Overview. Geriatric Overview. Chapter 26. Geriatrics 9/11/2012

Overview. Geriatric Overview. Chapter 26. Geriatrics 9/11/2012 Chapter 26 Geriatrics Slide 1 Overview Trauma Common Medical Emergencies Special Considerations in the Elderly Medication Considerations Abuse and Neglect Expanding the Role of EMS Slide 2 Geriatric Overview

More information

A Syndrome (Pattern) Approach to Low Back Pain. History

A Syndrome (Pattern) Approach to Low Back Pain. History A Syndrome (Pattern) Approach to Low Back Pain Hamilton Hall MD FRCSC Professor, Department of Surgery, University of Toronto Medical Director, CBI Health Group Executive Director, Canadian Spine Society

More information

Rotator Cuff Pathophysiology. treatment program that will effectively treat it. The tricky part about the shoulder is that it is a ball and

Rotator Cuff Pathophysiology. treatment program that will effectively treat it. The tricky part about the shoulder is that it is a ball and Rotator Cuff Pathophysiology Shoulder injuries occur to most people at least once in their life. This highly mobile and versatile joint is one of the most common reasons people visit their health care

More information

Doctor of Physical Therapy Degree Curriculum:

Doctor of Physical Therapy Degree Curriculum: Doctor of Physical Therapy Degree Curriculum: SUMMER SEMESTER 1 st YEAR (BOTH SESSIONS) DPT 744 Gross Human Anatomy I 2 credits DPT 744L Gross Human Anatomy I Lab 1 credit DPT 745 Gross Human Anatomy II

More information

SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D]

SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] SUBSTANCE USE DISORDER SOCIAL DETOXIFICATION SERVICES [ASAM LEVEL III.2-D] I. Definitions: Detoxification is the process of interrupting the momentum of compulsive drug and/or alcohol use in an individual

More information

Request for Designated Doctor Examination Type (or print in black ink) each item on this form

Request for Designated Doctor Examination Type (or print in black ink) each item on this form Texas Department of Insurance Division of Workers Compensation 7551 Metro Center Drive, Suite 100 MS-603 Austin, TX 78744-1645 (512) 804-4380 phone (512) 804-4121 fax Complete, if known: DWC Claim # Carrier

More information

Determine the Appropriate Level E/M Code Based on the Encounter

Determine the Appropriate Level E/M Code Based on the Encounter Determine the Appropriate Level E/M Code Based on the Encounter Jeffrey D. Lehrman, DPM, FACFAS, FASPS, FAPWH APMA Coding Committee Expert Panelist, Codingline.com Fellow, American Academy of Podiatric

More information

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557

JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 FIGHTING PAIN. TOUCHING LIVES. JAMES PETROS, M.D., INC. PHONE: (408) 528-8833 FAX: (408) 528-8557 Personal Information Emergency Contact Today s Date: Name: Patient: Realtionship: Birth Date: Age: Sex:

More information

SPINE. Postural Malalignments 4/9/2015. Cervical Spine Evaluation. Thoracic Spine Evaluation. Observations. Assess position of head and neck

SPINE. Postural Malalignments 4/9/2015. Cervical Spine Evaluation. Thoracic Spine Evaluation. Observations. Assess position of head and neck SPINE Observations Body type Postural alignments and asymmetries should be observed from all views Assess height differences between anatomical landmarks Figure 25-9 Figure 25-10 Figure 25-11 & 12 Postural

More information

National Registry of Emergency Medical Technicians Emergency Medical Technician Psychomotor Examination BLEEDING CONTROL/SHOCK MANAGEMENT

National Registry of Emergency Medical Technicians Emergency Medical Technician Psychomotor Examination BLEEDING CONTROL/SHOCK MANAGEMENT BLEEDING CONTROL/SHOCK MANAGEMENT Candidate: Examiner: Date: Signature: Possible Applies direct pressure to the wound 1 NOTE: The examiner must now inform the candidate that the wound continues to bleed.

More information

let s talk bleeds a bleed checklist for haemophilia patients

let s talk bleeds a bleed checklist for haemophilia patients let s talk bleeds a bleed checklist for haemophilia patients Specific signs of a bleed Watch for Bruising, with or without lumps Difference in the size of arms/legs Difference in movement in arms/legs

More information

THE BENJAMIN INSTITUTE PRESENTS. Excerpt from Listen To Your Pain. Assessment & Treatment of. Low Back Pain. Ben E. Benjamin, Ph.D.

THE BENJAMIN INSTITUTE PRESENTS. Excerpt from Listen To Your Pain. Assessment & Treatment of. Low Back Pain. Ben E. Benjamin, Ph.D. THE BENJAMIN INSTITUTE PRESENTS Excerpt from Listen To Your Pain Assessment & Treatment of Low Back Pain A B E N J A M I N I N S T I T U T E E B O O K Ben E. Benjamin, Ph.D. 2 THERAPIST/CLIENT MANUAL The

More information

1995 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES

1995 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES 1995 DOCUMENTATION GUIDELINES FOR EVALUATION AND MANAGEMENT SERVICES I. INTRODUCTION WHAT IS DOCUMENTATION AND WHY IS IT IMPORTANT? Medical record documentation is required to record pertinent facts, findings,

More information

SPINE, LOWER EXTREMITY, AND PELVIC IMPAIRMENT SECTION

SPINE, LOWER EXTREMITY, AND PELVIC IMPAIRMENT SECTION SPINE, LOWER EXTREMITY, AND PELVIC IMPAIRMENT SECTION Lev.II Curriculum Rev. 6/09 99 OBJECTIVES FOR SPINAL, LOWER EXTREMITY, AND PELVIC IMPAIRMENT RATING SECTION 1. Demonstrate ability to properly measure

More information

Clinic Director and Chiropractic Physician, Hiler Chiropractic, PA, Naples, Florida, January 2002 to present

Clinic Director and Chiropractic Physician, Hiler Chiropractic, PA, Naples, Florida, January 2002 to present Richard A Hiler, DC, CABVR, CICE 1234 Airport Pulling Rd North Naples, Florida 34104 Phone 239 659 2669 fax 239 659 2639 Hilerchiro@aol.com Selected Occupational History Clinic Director and Chiropractic

More information

EMR EMERGENCY MEDICAL RESPONDER Course Syllabus

EMR EMERGENCY MEDICAL RESPONDER Course Syllabus 6111 E. Skelly Drive P. O. Box 477200 Tulsa, OK 74147-7200 EMR EMERGENCY MEDICAL RESPONDER Course Syllabus Course Number: HLTH-0009 OHLAP Credit: No OCAS Code: 9373 Course Length: 66 Hours Career Cluster:

More information

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE

MOTOR VEHICLE ACCIDENT QUESTIONNAIRE MOTOR VEHICLE ACCIDENT QUESTIONNAIRE Thank you in advance for taking the time to complete this form, this will help us to better assess all of your pain concerns and provide you with the best treatment.

More information

Dear Potential Transfer Student,

Dear Potential Transfer Student, Dear Potential Transfer Student, Thank you for your interest in Faulkner State Community College s Nursing Program. The forms and checklist to be completed in order to be considered for transfer are enclosed.

More information

Diagnostic Imaging Exams

Diagnostic Imaging Exams Guide for Chiropractors Diagnostic Imaging Exams CREATED FOR OUR CHIROPRACTIC PARTNERS This document has been prepared by the specialized, board-certified radiologists who interpret patient exams for Center

More information

Patient Guide. Sacroiliac Joint Pain

Patient Guide. Sacroiliac Joint Pain Patient Guide Sacroiliac Joint Pain Anatomy Where is the Sacroiliac Joint? The sacroiliac joint (SIJ) is located at the bottom end of your spine, where the "tailbone" (sacrum) joins the pelvis (ilium).

More information

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598

Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Roswell Ear, Nose, Throat, & Allergy 342 W. Sherrill Lane Suite A, Roswell, New Mexico 88201 (575)-622-2911 Fax: (575)-622-2598 Patient Registration Form: (Please Print all Pertinent Information) Last

More information

An Effective Exercise Prescription for Ataxia. Polly Swingle, PT The Recovery Project, LLC www.therecoveryproject.net 734-953-1745

An Effective Exercise Prescription for Ataxia. Polly Swingle, PT The Recovery Project, LLC www.therecoveryproject.net 734-953-1745 An Effective Exercise Prescription for Ataxia Polly Swingle, PT The Recovery Project, LLC www.therecoveryproject.net 734-953-1745 1 Are you Functional? Sit to stand from a chair without the use of your

More information

Temple Physical Therapy

Temple Physical Therapy Temple Physical Therapy A General Overview of Common Neck Injuries For current information on Temple Physical Therapy related news and for a healthy and safe return to work, sport and recreation Like Us

More information

Cerebral Palsy. Causes

Cerebral Palsy. Causes Cerebral Palsy Cerebral Palsy (sera brul PAUL zee) (CP) is an injury or abnormality of the developing brain that affects movement. This means that something happened to the brain or the brain did not develop

More information

First Year. PT7040- Clinical Skills and Examination II

First Year. PT7040- Clinical Skills and Examination II First Year Summer PT7010 Anatomical Dissection for Physical Therapists This is a dissection-based, radiographic anatomical study of the spine, lower extremity, and upper extremity as related to physical

More information

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges

Requirements for Medical Clearance: History and Physical exam within 6 months of applying for privileges To: From: Re: Medical Staff Applicants K. Bruce Simmons, MD Director, Requirements for Medical Clearance EMPLOYEE/STUDENT HEALTH Jacobsen Hall 315-464-4260 (telephone) 315-464-5471 (fax) The New York Department

More information

Neurological and Trauma Impairment Set Version 10

Neurological and Trauma Impairment Set Version 10 Neurological and Trauma Impairment Set Version 10 Admission/Discharge - Neurological + Trauma Impairment Set Version 10 (Please circle reason for assessment) Name: Severity scores - extent to which deficit

More information

The file and the documentation should create a clean chronological record of the patient and their interactions with the provider.

The file and the documentation should create a clean chronological record of the patient and their interactions with the provider. Documentation and Coding Guidelines for Athletic Trainers Table of Contents What is documentation and why is it important? Documentation and SOAP What do payers want and why? General guidelines of medical

More information

Breast Center Bulletin

Breast Center Bulletin Breast Center Bulletin Published by the National Consortium of Breast Centers, Inc. This newsletter is an opportunity for members to discuss programs and products but does not represent an endorsement

More information

Compliant Documentation in the EHR. Introduction

Compliant Documentation in the EHR. Introduction Compliant Documentation in the EHR Lynn Myers MD, CPC, CHC 1 Introduction The perspective of a physician and a coder Going over to the dark side of medicine Death by a thousand cuts? Why it helps coders

More information

This is my information booklet: Introduction

This is my information booklet: Introduction Hip arthroscopy is a relatively new procedure which allows the surgeon to diagnose and treat hip disorders by providing a clear view of the inside of the hip with very small incisions. This is a more complicated

More information

Stretching the Low Back THERAPIST ASSISTED AND CLIENT SELF-CARE STRETCHES FOR THE LUMBOSACRAL SPINE

Stretching the Low Back THERAPIST ASSISTED AND CLIENT SELF-CARE STRETCHES FOR THE LUMBOSACRAL SPINE EXPERT CONTENT by Joseph E. Muscolino photos by Yanik Chauvin body mechanics THE ESSENCE OF MOST MANUAL THERAPIES, and certainly clinical orthopedic massage therapy, is to loosen taut soft tissues, thereby

More information