Lung Mass Evaluation Medical Documentation Template

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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.

Lung Mass Evaluation by e-MedTools

What are lung masses?

The discovery of a lung mass provokes great fear, because this discovery may be the first sign of lung cancer or other cancer. Because of the risk of cancer, a thorough and timely evaluation of a lung mass is imperative.

The Centers for Disease Control and Prevention states, ”More people die from lung cancer than any other type of cancer. This is true for both men and women. In 2003 (the most recent year for which statistics are currently available), lung cancer accounted for more deaths than breast cancer, prostate cancer, and colon cancer combined.”

In 2003 nearly 200,000 people were diagnosed with lung cancer. In that same year, 160,000 died from lung cancer. The treatment for lung cancer is not very effective, unless detected and treated in the earliest, often asymptomatic, stages.

Not all lung masses are due to cancer. Lung masses can develop as a result of infection, primarily tuberculous and fungal infections. Other disease processes associated with lung masses include rheumatoid arthritis, sarcoidosis, silicosis, and arteriovenous malformations.

Questions relating to smoking history, drug abuse, and alcohol abuse are standard in MedicalTemplates. These questions have increased importance in the evaluation of patients with lung masses. Patients who smoke are at 10-20 times more likely to develop lung cancer, and many other cancers (i.e., gastric, pancreatic, cervical, larynx, esophagus and colon cancer) are also related to smoking.

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 Lung Mass 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 Lung Mass 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.