E/M LEVEL WORKSHEET. Category. Subcategory (if applicable) (new/established, etc.)
|
|
|
- Jonathan Carr
- 9 years ago
- Views:
Transcription
1 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 (if applicable) (new/established, etc.) STEP 2: REVIEW THE REPORTING INSTRUCTIONS FOR THE SELECTED CATEGORY OR SUBCATEGORY Read the section-specific instructions for the selected category/subcategory. STEP 3: REVIEW THE LEVEL OF E/M SERVICE DESCRIPTORS (HISTORY, EXAM, MEDICAL DECISION MAKING, COUNSELING, COORDINATION OF CARE, NATURE OF PRESENTING PROBLEM AND TIME) Read the E/M service descriptors (history, exam, medical decision making, counseling, coordination of care, nature of presenting problem and time) STEP 4: DETERMINE THE EXTENT OF HISTORY OBTAINED a. Identify the Chief Complaint: b. Evaluate the HPI for the following elements: location (anatomical place, position or site of the chief complaint) severity (a degree or measurement of the severity) timing (when or at what frequency the problem is noticed) modifying factors (anything that makes the problem better or worse) quality (a problem s characteristics, such as how it looks or feels) duration (description of approx. duration of symptoms) context (description of how symptoms began) associated signs and symptoms (significant signs or symptoms patient feels are related to injury/illness or a lack thereof) HPI contains three or more chronic problems Total elements In addition to using the above elements, the level of the HPI can be based on the physician s documentation of the status of 3 or more of chronic problems. If the physician documents the status of 3 of more chronic problems the HPI would be counted as extended. Number of chronic problems referenced brief extended (1-3 brief, 4 or more extended, 3 or more chronic problems extended)
2 c. Analyze Review of Systems Constitutional (weight loss, fever, chills, malaise) Ear, nose, throat, and mouth (hearing loss, sinusitis, sore throat, oral cavities, ulcers) Gastrointestinal (nausea, vomiting, diarrhea, constipation, ulcer) Integumentary (skin rashes, moles, dryness, lumps, pigmentation) Endocrine (polyuria, polydypsia, cold-heat intolerance, diabetes) Genitourinary (hematuria, nocturia, menopause, hernia) Hematologic/lymphatic (anemia, bruising, bleeding, lymph node enlargement) Eyes (diplopia, blurred vision) Cardiovascular (chest pain or pressure, palpitations, murmur, hypertension) Musculoskeletal (arthritis, joint stiffness, swelling, myalgias, gout) Neurologic (dizziness, syncope, vertigo, weakness, tremor) Allergic/immunologic (allergies to medicine, food, dye; hepatitis; HIV) Respiratory (cough, hemoptysis, pleuritic chest pain, wheezing, asthma) Psychiatric (depression, agitation, panic-anxiety, memory disturbance) Total body systems covered Determine extent of ROS: None (no problem pertinent ROS/no ROS) Problem pertinent (problem pertinent ROS, one system) Extended (problem pertinent ROS w/limited additional systems (problem pertinent + at least one additional body system, up to nine) Complete (problem pertinent + all additional (minimum of 10) body systems) Analyze PFSH: Past medical history: Adult and childhood illnesses or trauma, vaccinations and screenings, past surgical history, and past and present medications Family history: Describes parents, siblings, children, genetic diseases of family or other family history Social history: Information about the patient s habits and circumstances (smoking, alcohol consumption, drug use, sexual orientation, marital status, place of birth, residence, occupation, education level, religion, recent travel destinations) Determine extent of PFSH None = No documented past, family, and/or social history Pertinent = Documentation of at least one item from any of the three history areas. Complete = Documentation of at least one item from two of three history areas or three of three history areas depending on E/M code type.
3 KEY COMPONENT: Extent of History Obtained: Problem focused (CC, brief HPI) Expanded problem focused (CC, brief HPI w/problem pertinent ROS) Detailed (CC, extended HPI w/extended ROS (1-9 add l body systems), pertinent PFSH) Comprehensive (CC, extended HPI w/extended ROS (10+ body systems), complete PFSH STEP 5: DETERMINE THE EXTENT OF EXAMINATION PERFORMED USING THE ELEMENTS OF EXAMINA- TION REFERENCE SHEET Identify body areas covered (check) and count elements: Chest, including breasts and axillae Elements: Neck trachea-larynx, thyroid Elements: Identify organ systems covered (check) and count elements: Constitutional Eyes Ears, nose, throat Cardiovascular Respiratory Gastrointestinal Genitourinary Musculoskeletal Skin Neurological Psychiatric Lymphatic Count elements and use Determining Extent of Examination Performed reference sheet to assign Level of Exam.
4 KEY COMPONENT: Extent of Examination Obtained: None Problem focused (one to five elements identified by a bullet) Expanded problem focused (at least six elements identified by a bullet) Detailed (at least two elements identified by a bullet from each of six areas/systems or at least twelve elements identified by a bullet in two or more areas/systems) Comprehensive (all elements in nine body areas/organ systems. For each area/system, documentation of at least two elements identified by a bullet is expected) STEP 6: DETERMINE THE COMPLEXITY OF MEDICAL DECISION MAKING Identify and classify problem as self-limited, minor, established stable or improved, or established worsening. If problem is new, determine if additional workup is planned. Use the DMO Table to determine points. DIAGNOSIS/MGMT OPTIONS TABLE (NUMBER X POINTS = TOTAL NUMBER POINTS TOTAL Self-limited or minor problem 1 Established problem (to provider) stable or improved 1 Extablished problem (to provider) worsening 2 New problem (to provider) no additional work up planned 3 New problem (to provider) additional work up planned 4 Total Points Max number of self-limited or minor problems = 2 Max number of new problem no additional work planned = 1 Assign Diagnosis/Mgmt Options Level: 1 point = Straightforward 2 points = Low 3 points = Moderate 4+ points = High Identify Data to be Reviewed elements in the medical record.
5 TABLE OF AMOUNT AND/OR COMPLEXITY OF DATA TO BE REVIEWED POINTS Review and/or order of clinical lab tests 1 Review and/or order of radiology section test 1 Review and/or order of medicine section test 1 Discussion of test results with performing physician 1 Decision to obtain old records and/or obtaining history from someone other than the patient 1 Review and summarization of old records and/or obtaining history from someone other than the patient and/ 2 or discussion of case with another healthcare provider Independent visualization of image, tracing, or specimen (not only the report) 2 Total Points Assign Amount and/or Complexity of Data Level: 0-1 point = Straightforward 2 points = Low 3 points = Moderate 4+ points = High Table of Risk Presenting Problem Diagnostic Procedures Ordered Management Options Selected
6 Assign the Level of Risk (highest of presenting problem, diagnostic procedures ordered, and management options selected): Diagnosis/Mgmt Options, Amount and/or Complexity of Data to be Reviewed, and Level of Risk are analyzed to determine extent of MDM obtained (2 out of 3 must be met or exceeded). KEY COMPONENT: Extent of MDM Obtained: medical decision making Medical decision making of low complexity Medical decision making of moderate complexity Medical decision making of high complexity STEP 7: SELECT THE APPROPRIATE LEVEL OF E/M SERVICES Career Step, LLC All Rights Reserved.
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
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
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
(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
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
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
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
St. Luke s MS Center New Patient Questionnaire. Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor?
St. Luke s MS Center New Patient Questionnaire Name: Date: Birth date: Right or Left handed? Who is your Primary Doctor? Who referred you to the MS Center? List any other doctors you see: Reason you have
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
NEW PATIENT HISTORY QUESTIONNAIRE. Physician Initials Date PATIENT INFORMATION
NEW PATIENT HISTORY QUESTIONNAIRE Physician Initials Date PATIENT INFORMATION JHH# DOB# AGE HOME PH CELL PH DAY PH EMAIL Who is your REFERRING PHYSICIAN? (The doctor who referred you to Johns Hopkins Neurology.)
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
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
NEW PATIENT CONSULTATION FORM. Social Security Number - - Date of Birth Age. Home Address. Home phone Cell phone. Work phone Email address
NEW PATIENT CONSULTATION FORM Welcome to our office. Please fill out the first four pages. Date Name Social Security Number - - Date of Birth Age Home Address Home phone Cell phone Work phone Email address
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
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
Plano Heart Center, P.A.
Plano Heart Center, P.A. Date: How did you hear about us: Physician Referral Advertisement Friend Other. Please specify: Patient Information Name: Social Security #: Address: City: State: Zip: Home Ph:
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
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
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591
Southwest General Surgical Associates General & Vascular Surgery 8230 Walnut Hill Lane Suite 408 Dallas, TX 75231 Phone-214)369-5432 Fax-214)369-5591 Andres U. Katz, M.D. Richard S. Anderson, M.D. G. Thomas
POINCIANA INTERNAL MEDICINE PA. Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address:
Patient Name: Social Security Number: Date of Birth: / / Sex: M/F (Circle One) Married/Single/Divorced/Widow Address: (Street) (City/State/Zip) Home Phone: ( ) E Mail Address: Would you be interested in
CLINIC APPLICATION. Client Information
ICNA Relief USA Shifa Free Medical Clinic 1092 Johnnie Dodds Boulevard, Suite 108 Mount Pleasant, SC 29464 Tel: (843) 352-4580 Fax: (843) 375-9063 Last Name Street Address City, State, Zip Code Home Phone
1MFBTF GJMM PVU GPSNT BOE GBY 'PSNT XJMM CF TJHOFE BU ZPVS BQQPJOUNFOU
CELL PHONE: PATIENT HISTORY FORM - CONFIDENTIAL DATE: PATIENT: (LAST NAME) (FIRST NAME) (Ml) (NICKNAME) DOB: Primary Physician/ Family Doctor: Phone: Past Medical History (Click all that apply) High blood
New Patient Intake Form
New Patient Intake Form Title: (Circle one) Mr. Mrs. Ms. Miss Dr. Other First Name Middle Initial Last Name Address City State Zip Code Leave Messages on: (Circle one) Home Cell Work Don t leave messages
Southwestern Foot & Ankle Associates, P.C. 3880 Parkwood Blvd, Suite 602 Frisco, TX 75034 Phone: 972-335-9071 Fax: 972-335-8920 Dr. Thomas H.
Phone: 972-335-9071 Fax: 972-335-8920 Date: Home Phone ( ) Patient Information (Please Print) Email: Name: SS/Patient ID # Last Name First Name Middle Initial Address Cell Phone ( ) City State Zip Sex
PELED PLASTIC SURGERY HEADACHE HISTORY FORM
HEADACHE HISTORY FORM IF THIS IS YOUR FIRST VISIT, PLEASE TAKE THE TIME TO FILL THIS FORM OUT COMPLETELY. Patient Name: Age: Date of Birth: Weight: Height: Address: City: State: Zip: Home Phone: Cell Phone:
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach
Application For Admission To The Non-Surgical Spinal Decompression Program At The Spinal Decompression Center of Long Beach If you are reading this form, you have qualified for a consultation with Dr.
LOEWENBERG SCHOOL OF NURSING LOEWENBERG SCHOOL OF NURSING HEALTH EXAMINATION FORM (FORM 003)
SECTION I: To be completed by STUDENT: Name: DOB: Address: Phone (H): Phone (C): Health History: Please complete the following information: Recent weight loss or gain Fatigue, fever, sweats Difficulty
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:
Community Internal Medicine of Athens 1500 Oglethorpe Avenue Suite 200D Athens, GA 30606 Phone: (706) 389-3875 Fax: (706) 389-3876
Please Fill Out Completely: Community Internal Medicine of Athens Phone: (706) 389-3875 Fax: (706) 389-3876 Patient s Last Name First Name MI Social Security Number Date of Birth Age Gender Race Marital
Patient Registration Form
PATIENT INFORMATION Patient Registration Form (Please Print) Dr. Miss Mr. Mrs. Ms. Sir Jr. Sr. Patient s Name (Last) (First) (MI) Previous Name Mailing Address City, State, ZIP (+4) Physical Address City,
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,
Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684 Phone (727) 784-3366 FAX (727) 784-3527
Jerry Drucker, MD, FACE The Endocrine Center of Florida, LLC Board Certified Internal Medicine 34041 US Highway 19 North, Suite C Board Certified Endocrinology, Diabetes & Metabolism Palm Harbor, FL 34684
IF THIS IS RELATED TO A WORKMAN S COMPENSATION CLAIM OR AN AUTOMOBILE ACCIDENT, PLEASE FILL OUT ADDITIONAL SHEET IN THE BACK OF THIS PACKET (PIP FORM)
PATIENT INFORMATION Last Name: First: MI: of Birth: Social Security #: - - Address: City State Zip Home#: ( ) - Cell#: ( ) - Employer: Employer#: ( ) - Occupation: Retired Unemployed Student Self-Employed
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
Surgery Health Survey
Surgery Health Survey Name: Social Security Number: Date of Birth: Please tell us which physician(s) we should contact regarding your visit: REFERRING PHYSICIAN Name: Address: PRIMARY CARE PHSYICIAN Name:
How to Remove a Social History Smoke?
AUSTIN RETINA ASSOCIATES PATIENT INFORMATION NAME: MAILING ADDRESS or NURSING HOME NAME & ADDRESS: Last First Middle Initial CITY: STATE: ZIP CODE: - TELEPHONE: HOME:( ) CELL: ( ) WORK:( ) DATE OF BIRTH:
PODIATRIC ASSOCIATES OF NW OHIO, INC. PATIENT HISTORY INSURANCE INFORMATION
PODIATRIC ASSOCIATES OF NW OHIO, INC. DATE PATIENT HISTORY PATIENT S LAST NAME FIRST NAME MIDDLE SOCIAL SECURITY NUMBER ADDRESS STREET APT. NO. CITY STATE ZIP DATE OF BIRTH AGE SEX MARITAL STATUS HOME/CELL
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
1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form
Mail completed form to: Marlin Health Services 1584 Wesleyan Drive FORM A Norfolk, VA 23504 Phone: (757) 455-3108 Health History immunization & Physical Form Virginia State law (code 23-7.5) requires all
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
NORTHEAST SPINE & SPORTS MEDICINE PATIENT INTAKE MAILING ADDRESS: CITY: STATE: ZIP CODE: HOME PHONE#: CELL#: WORK PHONE#: S / M / D / W
NORTHEAST SPINE & SPORTS MEDICINE PATIENT NAME: PATIENT INTAKE SOCIAL SECURITY#: SEX M/F: DATE OF BIRTH: AGE: MAILING ADDRESS: CITY: STATE: ZIP CODE: EMAIL ADDRESS: HOME PHONE#: CELL#: WORK PHONE#: EMPLOYER:
Women s Continence and Pelvic Health Center
Women s Continence and Pelvic Health Center Committed to Caring 580-590 Court Street Keene, New Hampshire 03431 (603) 354-5454 Ext. 6643 URINARY INCONTINENCE QUESTIONNAIRE The purpose of this questionnaire
Pulmonary Associates of Richmond
Pulmonary Associates of Richmond Name: Address One: City: Home Phone#: Work Phone#: Cell Phone#: State: Zip: Sex: Social Security Number: Referring Doctor: of Birth: Employer: Primary Care Doctor: Employment
Financial/Office Policy Brandon Family Medical Care, P.A. 414 West Robertson Street Brandon, Florida 33511 (813) 684-5255
Brandon B Family MEDICAL CARE Financial/Office Policy The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make
Documentation Guidelines for Physicians Interventional Pain Services
Documentation Guidelines for Physicians Interventional Pain Services Pamela Gibson, CPC Assistant Director, VMG Coding Anesthesia and Surgical Divisions 343.8791 1 General Principles of Medical Record
New England Pain Management Consultants At New England Baptist Hospital
New England Pain Management Consultants At New England Baptist Hospital Pain Management Center Health Assessment Dear New Pain Management Patient, Welcome to the New England Pain Management Consultants
North Carolina Orthopaedic Clinic Patient Registration Form
North Carolina Orthopaedic Clinic Patient Registration Form FOR US TO PROCESS YOUR CHART, PLEASE COMPLETE FULLY AND PRINT CLEARLY PATIENT INFORMATION NAME: BIRTHDATE: AGE: TODAY S DATE: SOCIAL SECURITY
Coding Flow Charts. What is Medical Coding? 9/17/2012. Diagnosis Codes ICD-9-CM. Volume 1 & 2* Speakers
Speakers Welcome to Coding Basics - Essentials You Must Know to Thrive Brought to you by ACC s Cardiovascular Administrator Work Group Presented by the ACC in conjunction with the MedAxiom Business Office
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792
The NeuroCenter Swedish Covenant Medical Group 6225 W. Touhy Ave, Chicago, Il 60646 Tel: 773-775-7540 Fax: 773-763-9792 1 PAIN MANAGEMENT SERVICES New Patient Questionnaire Date: Primary MD: Referring
Empire BlueCross BlueShield Professional Reimbursement Policy
Subject: Documentation and Reporting Guidelines for Evaluation and Management Services NY Policy: 0024 Effective: 12/01/2013-03/31/2014 Coverage is subject to the terms, conditions, and limitations of
Associated Ear, Nose & Throat Specialists, LLC. OCCUPATION: Employer: Work Phone: PHYSICIAN REQUESTING CONSULTATION: TOWN: PHONE:
Associated Ear, Nose & Throat Specialists, LLC Todd A. Zachs, M.D. Kevin C. Krebsbach, M.D Thomas Hinchey, Au.D., CCC-A Amanda Hessenauer, Au.D. Name: Birth date: SOCIAL SECURITY SEX: M F (IF MINOR) PARENT'S
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER
SOUTH TAMPA MULTIPLE SCLEROSIS CENTER PATIENT/CARE GIVER QUESTIONNAIRE DEMOGRAPHIC INFORMATION Patient's Name: City: State: Zip Code: Phone: Marital Status: Spouse/Care Giver Name: Phone (H) (W) Occupation:
NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES
NEW YORK STATE MEDICAID PROGRAM MIDWIFE PROCEDURE CODES Table of Contents GENERAL INFORMATION... 3 SERVICES PROVIDED IN ARTICLE 28 FACILITIES... 4 MMIS MODIFIERS... 4 MEDICINE SECTION... 7 GENERAL INFORMATION
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
MEDICAL-SURGICAL EYE CARE, P.A.
MEDICAL-SURGICAL EYE CARE, P.A. DATE PATIENT'S NAME: ADDRESS: CITY/STATE/ZIP: DATE OF BIRTH: MARTIAL STATUS: M S D W HOME PHONE: ( ) SEX: M F AGE: CELLPHONE: ( ) IF CHILD; PARENT OR GUARDIAN NAME: EMERGENCY
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
OFFICE POLICY. I, have read and understand the Financial Policy of Brandon Family Medical Care and agree to meet all financial obligations.
OFFICE POLIC The doctors and staff at Brandon Family Medical Care would like to welcome you to our Practice. Our goal is to provide excellent medical care and make your visits as convenient as possible.
PATIENT INFORMATION / / OTHER CONTACT NUMERS: (CIRCLE ONE) CELL, HOME OR OTHER. ENTER NUMBER BELOW. ( ) EMPLOYER ( )
PATIENT INFORMATION PATIENT S LEGAL NAME DATE OF BIRTH AGE DATE / / / / HEIGHT AND WEIGHT SEX REASON FOR VISIT: MARITAL STATUS FT IN LBS MALE FEMALE S M D W ADDRESS CITY STATE ZIP CODE THE BEST NUMBER
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE
NEW YORK SPINE & PAIN PHYSICIANS NEW PATIENT QUESTIONNAIRE DEMOGRAPHICS- To be completed by all patients Patient Name: Today s Date: / / Patient Address: _ City: State: Zip: Home Phone #: ( ) - Work #:
RETINA CARE CENTER, P.C. PATIENT INFORMATION
RETINA CARE CENTER, P.C. JONATHAN M. BAROFSKY, M.D., F.A.C.S. Parkway Seventy Plaza 1255 Route 70, Suite 31N Lakewood, New Jersey 08701 PHONE (732)905 0004 FAX (732)905 3868 PATIENT INFORMATION Welcome
Workman s Compensation
Workman s Compensation Name: Sex: Phone Number: Age: Address (Street/City/State/Zip) Name of Employer: Phone: Address of Employer (Street/City/State/Zip) Date and time of accident?: Where were you taken
***************PATIENT INFORMATION****************
SEP BADY, MD ***************PATIENT INFORMATION**************** TODAYS DATE: / / WHICH DOCTOR ARE YOU SEEING? BADY KURUVILLA LIU OTTEN TRAINOR YEE PATIENT LAST NAME: FIRST: MIDDLE INITIAL: ADDRESS: CITY/STATE:
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.
Forms designed to collect this information will help staff collect all pertinent information.
1 CPT AUDIT TOOL INSTRUCTIONS The Nursing Consultants from the Public Health Nursing and Professional Development Unit based on multiple Evaluation & Management audits across the state have developed these
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
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.
General Internal Medicine Clinic New Patient Questionnaire
General Internal Medicine Clinic New Patient Questionnaire Date: Name: What would you like to be called by the doctor? Marital Status: Please list how you would like to be contacted, for test results:
NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.
DATE NEUROSURGERY SERVICES AT APD LOCATED AT UPPER VALLEY MEDICAL GROUP 106 Hanover Street, Lebanon, NH 03766 Phone: 603.448.0447 Fax: 603.448.0019 Joseph M. Phillips, M.D., Ph.D. Board Certified in Pain
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD
OMNI DERMATOLOGY, INC. NEW PATIENT INFORMATION RECORD Name Last: First: MI: Social Security Number: Date of birth: / / Sex: M F Address: Street City State: Zip Code: Contact Numbers: Home Phone: ( ) -
PATIENT SELF-ASSESSMENT FORM
PATIENT SELF-ASSESSMENT FORM Please complete the information below to the best of your ability. Personal Information Name: Address: City: State: Zip: Telephone: Email: Name of referring physician: Address:
PATIENT DEMOGRAPHICS
PATIENT DEMOGRAPHICS Prefix: Patient's First Name: Preferred Name: M.I.: Last Name: Mailing Address: Apt: City: State: Zip Code: Social Security No. (necessary for billing): Guardian's Last Name (if patient
Please review, complete, and return all paperwork included in this packet. If you have any questions or concerns please feel free to contact us at
Your child has been referred to the Health4Life Program at Children's Healthcare of Atlanta. We are located at the Scottish Rite Campus in the Medical Office Building. In order to serve you and your child
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet
PLEASE COMPLETE PRIOR TO VISIT***Place your name at the bottom of each sheet GASTROINTESTINAL ASSOCIATES, INC. PATIENT REGISTRATION Welcome to our practice. Please complete all sections of this registration
NEW YORK STATE MEDICAID PROGRAM PHYSICIAN PROCEDURE CODES. SECTION 2 MEDICINE, DRUGS and DRUG ADMINISTRATION
NEW YORK STATE MEDICAID PROGRAM PHYSICIAN PROCEDURE CODES SECTION 2 MEDICINE, DRUGS and DRUG ADMINISTRATION Table of Contents GENERAL RULES AND INFORMATION... 3 MMIS MODIFIERS... 15 EVALUATION AND MANAGEMENT
Insured Party Information (please complete if the insurance is not in your name)
Price M. Kloess, M.D. / Andrew J. Velazquez, M.D. / J. Randall Pitts, M.D. Holly Young, O.D./ Audrey Richards, O.D./ Brittany M. Mitchell, O.D. Patient Registration and Financial Agreement Patient s Dr
MEDICAL HISTORY AND SCREENING FORM
MEDICAL HISTORY AND SCREENING FORM The purpose of preventive exams is to screen for potential health problems and provide education to promote optimal health. It is best practice for chronic health problems
Name Home phone Work phone. Address. Email address. Date of birth Gender (circle): M F Marital status No. of children. Name of partner Referred by
Name Home phone Work phone Address Email address Date of birth Gender (circle): M F Marital status No. of children Name of partner Referred by Have you ever seen a Chiropractor? No Yes (Who?): Insurance
Evaluation & Management Place of Service
Evaluation & Management Place of Service Hoda Henein, CHBME, CP President & CEO, Active Management A Practice Management Consulting and Billing Company Fellow, Speaker, Billing & Coding Advisor American
PATIENT DEMOGRAPHICS:
PATIENT DEMOGRAPHICS: Last Name: First: MI: Address: City: State: Zip: Please check off the phone numbers you would like us to call regarding appointment conformations. Home: Cell: May we leave a message?
NEW PATIENT CLINICAL INFORMATION FORM. Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute
NEW PATIENT CLINICAL INFORMATION FORM Booth Gardner Parkinson s Care & Movement Disorders Center Evergreen Neuroscience Institute Date: Name: Referring Doctor: How did you hear about us? NWPF Your Physician:
INSURANCE INFORMATION FINANCIAL AGREEMENT PRIVACY POLICY (HIPAA) LIFETIME INSURANCE AUTHORIZATION
PATIENT INFORMATION: DATE: NAME (LAST, FIRST, MI) ADDRESS CITY, STATE, ZIP PHONE ALTERNATE PHONE BIRTHDATE SEX MARITAL STATUS SOCIAL SECURITY RACE/ETHNICITY (please circle): American Indian or Alaskan
PATIENT REGISTRATION FORM
PATIENT REGISTRATION FORM PATIENT INFORMATION Patient s Name: First Middle Initial Last DOB: / / Address: City: State: Zip: Primary Phone: - - Secondary Phone: - - Email: (for patient portal purposes only)
Shelby Foot & Ankle 1. PATIENT INFORMATION 2. INSURANCE. 50505 Schoenherr Road, Suite 230 Shelby Township, MI 48315 (586) 580-3728 www.shelbyfoot.
: 1. PATIENT INFORMATION 2. INSURANCE SS/H/C/Patient ID#: Patient Last Name: Who is responsible for this account? Relationship to Patient: Insurance Co.: Patient First Name: Middle Int: Group #: Address:
PATIENT INFORMATION (Please Print) Patient First Middle Initial Last. Email : ( Please avoid using Work Email Address)
PATIENT INFORMATION (Please Print) Date: Patient First Middle Initial Last Birthdate: / / Marital Status: Address: City: State: Zip Code: Primary Phone: ( ) Secondary Phone: ( ) By supplying your email
PROFESSIONAL BILLING COMPLIANCE TRAINING PROGRAM MODULE 2 EVALUATION AND MANAGEMENT (E/M) SERVICES
PROFESSIONAL BILLING COMPLIANCE TRAINING PROGRAM MODULE 2 EVALUATION AND MANAGEMENT (E/M) SERVICES Evaluation and Management (E/M) Documentation E/M Documentation Background: Physician payment for inpatient
PLEASE PRINT LEGIBLY
Patient Information PLEASE PRINT LEGIBLY Patients Name: Date of Birth: Sex: Patients Address: City: State: Zip: Home Phone: Cell: Work: Email: SSN: Employer: Occupation: Marital Status: Employed: Full
Dear Patient, Sincerely, Gastroenterology Associates of North Jersey
GASTROENTEROLOGY ASSOCIATES OF NORTH JERSEY, P.A. Doctors Park 369 West Blackwell Street, Dover, NJ 07801 16 Pocono Road, Suite 210, Denville, NJ 07834 Tel (973) 361-7660 Fax (973) 361-0455 Tel (973) 627-7600
Florida Eye Center Patient Registration Form (Please Print Clearly)
Florida Eye Center Patient Registration Form (Please Print Clearly) Personal Information Legal Name: Last First MI Suffix Nickname: Social Security: - - Drivers License # Date of Birth: / / Mailing Address:
INITIAL PATIENT QUESTIONNAIRE-
Date: Patient Address: Home Phone: Work Phone: Age: Height: cm/inches Weight: kg/lbs Male Female Referring Physician s Name: Physician Phone: Physician Address: Type of Practice (Internist, Surgeon, etc.):
PATIENT INFORMATION INSURANCE INFORMATION
(mm/dd/yyyy): Have you been to Physicians Urgent Care before? Yes No Arrival Time: If yes, when? Is this a follow-up to a previous visit: Yes No PATIENT INFORMATION Patient s First Name: Middle Name: Last
Interventional Spine Pain Consultants, P.A. Initial Consultation Information
Interventional Spine Pain Consultants, P.A. Initial Consultation Information Date: / / Date of Birth / / Age: Name: Name of the provider that recommended you to our office? Name of your primary care doctor?