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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.
What is Interstitial Lung Disease?
Interstitial Lung Disease (ILD) is a diverse group of more than 200 diseases that cause progressive fibrosis (scarring) of lung tissue, which leads to chronic, progressive breathlessness and respiratory failure. The Pulmonary Fibrosis Foundation (www.pulmonaryfibrosis.org) estimates that more than 200,000 Americans have ILD, and nearly 40,000 Americans die each year from ILD.
ILD includes idiopathic pulmonary fibrosis (IPF), sarcoidosis, hypersensitivity pneumonitis, Nonspecific Interstitial Pneumonitis (NSIP), Desquamative
Interstitial Pneumonitis (DIP), Cryptogenic Organizing Pneumonia (COP, aka BOOP), medication induced lung disease, post-radiation fibrosis, and many other diseases.
The primary symptoms of ILD are nonspecific, such as non-productive cough and progressive breathlessness. These symptoms are seen in many other medical conditions such as asthma, heart failure, or chronic obstructive pulmonary disease (COPD). The lack of specificity of the presenting symptoms makes the identification of ILD challenging, particularly in individuals with known heart or lung disease. Early and accurate diagnosis of ILD is essential so that treatment options can be considered before extensive and permanent damage occurs, resulting in disabling breathlessness. While there is currently no proven, FDA-approved treatment for idiopathic pulmonary fibrosis, many forms of interstitial lung disease can be treated, if detected early in the disease process. Thus, having a low threshold for suspecting interstitial disease, and assessing a patient’s risk of developing pulmonary fibrosis by obtaining important historical information is critical to early diagnosis.
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 interstitial lung disease Evaluation medical documentation template
- HGSA Documentation worksheet
- 1997 Documentation Guidelines for Evaluation and Management Services
- 1995 Documentation Guidelines for Evaluation and Management Services
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 interstitial lung disease 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.