This COPD (Chronic Obstructive Pulmonary Disease) Evaluation medical documentation template is designed for use by all health care providers in the outpatient setting. The template is in a fillable PDF format by Adobe Acrobat and contains checkboxes and fillable textboxes.
This COPD Evaluation Template has generous space for documenting the HPI, and contains prompters that readily distinguish the severity of illness and recent symptoms or events that may indicate a need for changes in the COPD medication regimen, or even hospitalization.
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.
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:
- Chief Complaint (CC)
- History of Present Illness (HPI)
- Past Family and Social History (PFSH)
- Review of Systems (ROS)
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
- 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 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.