Medical Documentation template for initial evaluation of COPD

The COPD evaluation medical documentation template is suitable for hospitalists, internal medicine physicians, family practice physicians, pulmonologists, and other health care providers that evaluate patients with known or suspected COPD in ambulatory or hospital settings. This medical documentation template is a fillable Adobe PDF and is designed to improve the efficiency and quality of care in patient with COPD. It is suitable for use as a history and physical, consult note, or follow up note. Licenses for our medical documentation templates start at $99 for a single user. Volume discounts are available. When completed, and in conjunction with a supporting level of medical decision making, this medical documentation template meets or exceeds the documentation requirements in the 1995 and 1997 Medicare Guidelines for E&M services for the highest level of service.

Chronic Obstructive Pulmonary Disease Evaluation by e-MedTools

Impact of COPD on the US Healthcare system

The National Center for Health Statistics reports COPD to be the 4th leading cause of death in the Unites States, causing 124,000 deaths per year. Over 24 million Americans have COPD, and women are more likely than men to die from COPD. The major risk factor for developing and dying from COPD is tobacco smoking. COPD is responsible for over 1 million hospital admissions and $37 billion dollars in healthcare costs each year. Due to the large numbers of Americans with COPD and the heath care costs associated with the treatment of COPD, this chronic lung disease is a focus of many quality improvement initiatives and pay for performance programs.

What needs to be documented for E&M services?

The 1997 E&M Documentation Guidelines state that each patient encounter must include a medical history, examination, and medical decision making (MDM). Each documentation component requires certain types of information to be documented in the medical record. Documentation Components from the 1997 Guidelines: Medical History
  • Chief Complaint (CC)
  • History of Present Illness (HPI)
  • Past Family and Social History (PFSH)
  • Review of Systems (ROS)
Physical Exam Medical Decision Making (MDM)
  • The number of diagnosis or management options
  • Amount and complexity of medical data reviewed
  • Risk of significant complications, morbidity, or mortality

How can I use this medical documentation template to improve medical billing?

Using this documentation template will give you the confidence to bill at the highest level that is appropriate for the medical service you provided. This will maximize your clinical revenue and may help you identify ways to improve your documentation to reduce your RAC audit risk. Selecting the appropriate level for E&M services is challenging for most physicians. Studies show that 30-80% of outpatient E&M services are under coded, representing millions of dollars of lost practice revenue per year [Holt 2010].

References for this COPD Evaluation medical documentation template

Important note about medical decision making

Health care providers in Colorado, New Mexico, Oklahoma, Texas, and the Indian Health Service must used the method developed by Trailblazer Health, the local Medicare Carrier, to determine the complexity of Medical Decision Making.

Requirements to use the COPD Evaluation medical documentation template

This medical documentation template is in the Adobe PDF format, which requires the free Adobe Reader to function. With Adobe Reader, these templates can be filled out and printed as many times as you need.

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