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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 a pleural effusion?
A pleural effusion is a collection of excess fluid in the pleural space which is between the lungs and the chest wall. Chest pain and difficulty breathing are the most common symptoms.
Pleural effusions are concerning because they can indicate the presence of malignancies, such as lung cancer, lymphoma, metastatic cancer, or rarely, mesothelioma. Fortunately, the most common causes of pleural effusions are a wide range of treatable medical conditions such as congestive heart failure (CHF), pneumonia, pancreatitis, lupus, kidney disease, liver disease, tuberculosis, and others. Because so many medical conditions can be associated with pleural effusions, it can be difficult to positively determine the etiology.
Determining the cause of the pleural effusion requires a detailed medical and occupational history that includes outside interests, such as hobbies, and a complete physical exam. All new pleural effusions of substantial volume must be evaluated by a thoracentesis. This is done by inserting a needle or tube into the pleural fluid, and sending the fluid for laboratory analysis. Laboratory analysis includes evaluation of the presence of bacteria, inflammatory cells, cancer cells, proteins indicative of tuberculosis, esophageal rupture or urinothorax, or antibodies indicative of autoimmune disease.
The pleural effusion evaluation medical documentation template provides historical and laboratory prompters for the physician, facilitating a thorough and efficient investigation. Much of the documentation is done by clicking on checkboxes. Text boxes are provided to facilitate individualized documentation of the history, physical exam and impression and plan.
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 Pleural Effusion 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 Pleural Effusion 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.