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I need help with e/m level state.

  1. Default I need help with e/m level state.
    Exam Training Packages
    I have a template my doctor has created and wants to know how can we make this a level 4 or what is the highest level we can get on this. Please see below. KEEP IN MIND WE DO HAVE A LITTLE STICKER ON THE SIDE OF THE CHART THAT MA RECORDS THE VITAL SIGNS, WEIGHT.


    ACUTE GASTROENTERITIS

    ___ DAYS TEMP_____


    FEVER Y N DEHYDRATION Y N _____%
    NAUSEA Y N ABDOMEN TENDER Y N DIFFUSE ___q
    VOMITING Y N BOWEL SOUNDS Y N
    ANOREXIA Y N PERITONEAL SIGNS Y N
    ABDOMINAL PAIN Y N LUNGS CLEAR Y N
    CRAMPING Y N ENT CLEAR Y N
    DIARRHEA Y N
    HEMATEMESIS Y N
    HEMATOCHEZIA Y N
    RECENT TRAVEL Y N
    ANTBX/NSAID USE Y N DURATION_________
    MEDS TRIED Y N __________

    ENTERITIS GASTRITIS GASTROENTERITIS

    STOOL O&P C&S C.DIFICILE OCCULT BLOOD WBC CBC ESR BMP H.PYLORI


    ANTIDIARRHEAL OTC RX__________
    ANTIEMETIC OTC RX__________
    ANTISPASMODIC OTC RX__________

    DIET: CLEAR LIQUIDS BRAT DAIRY RESTRICTED REGULAR

    FLUIDS ACETAMINOPHEN REST RTW_______


    THANKS IN ADVANCE
    MSMADDY
    Last edited by MsMaddy; 11-04-2009 at 11:52 AM.

  2. #2
    Default
    Is this the entire note?

    All I see are 2 elements of HPI, ___Days, Meds tried
    2 ROS, Social history, and a little bit of exam for cons and GI.

    The history is stuck at EPF, under 97 exam is PF under 95 EPF, your MDM will vary obviously, but the best I could come up with is a 99213.

    Not an ideal template in my opinion at all.

    Laura, CPC, CEMC

  3. Default
    Yes it is the only note. So what else do you recommend should be added on?
    This isn't so much of a template, it like one of those sticker doctors use for pt who comes in for URI, BRONCHITIS, PHARYNGITIS.

    Thanks
    msmaddy

  4. #4
    Location
    Milwaukee WI
    Posts
    4,466
    Default Please see my remarks in Family Practice
    Ms Maddy,
    I answered a similar question you posted on the Family Practice forum where you asked about a "vaginitis" template.

    The same general comments apply here, so please take a look at my response on that other forum.

    A template for commonly seen problems CAN be a good way to ensure that you capture all the medically necessary documentation. BUT you need to be sure that you are not just completing boxes to get a higher level, but rather are performing a medically necessary service (and then documenting the service that was performed).

    Hope that helps.

    F Tessa Bartels, CPC, CEMC

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