Evaluation and Management Note The E/M note should be launched when the user attempts to reconcile a planned event with a service code of 309 E/M Service

Evaluation and Management Note

The E/M note should be launched when the user attempts to reconcile a planned event with a service code of 309 E/M Service (unspecified) or enter a 309 service using unplanned event entry. The program should store the planned event key for removal at the completion of the note; the PE should be written to the ISN PE record at that time.

The system should determine whether the consumer in question is a “new patient” or “established patient” based on a search of events in the system. Any consumer with an event in the system within three years of the date of service where mw:IsPrescriber(E.STAFF) = true should be considered an established patient; otherwise they should be considered a new patient. Note: we need to confirm this, but I think this should be limited to events where ISN.FC.CPT is data-present; non-billable services shouldn’t count. On the other hand, we don’t want to skip a service being “held” for submission but that might eventually be submitted. I’m not sure if this would ever happen, however.

Standard MHCD form header w/ consumer info

Evaluation and Management

Guidance from CMS:A CC is a concise statement that describes the symptom, problem, condition, diagnosis, or reason for the patient encounter.

The CC is usually stated in the patient’s own words.For example, patient complains of upset stomach, aching joints, and fatigue.

The medical record should clearly reflect the CC.

1000

Chief complaintCC.

HPI.

ROS.

PFSH.

Save CancelFinish

Last Saved - 4:04 pm Save

[Text required to finish section.]

History Exam Assessment Plan of CareCounseling Coordination Psychotherapy


History Exam Assessment Plan of Care


CC.

HPI.

ROS.

PFSH.

Save CancelFinish


Acute/New ConditionAcute/New Condition

Chronic Condition

History of Present Illness

Location

Severity

Timing

[Brief/Extended]

Quality

Duration

Context

ModifyingFactors

Associated Signs/Sx

Add New Condition

Brief description of Condition

Counseling Coordination Psychotherapy




CC.

HPI.

ROS.

PFSH.

Save CancelFinish


Chronic ConditionAcute/New Condition

Chronic Condition

History of Present Illness

[Brief/Extended][Brief Description] entered on MM/DD/YYYYLocation: text (show line only if data-present)Severity: text (show line only if data-present)Timing: text (show line only if data-present)Quality: text (show line only if data-present)Duration: text (show line only if data-present)Context: text (show line only if data-present)Modifying Factors: text (show line only if data-present)Associated Signs and Symptoms: text (show line only if data-present)

Status of Condition

[Show all conditions in scrolling box]

Status update entered on MM/DD/YYYYUpdate text




Review of SystemsCC.

HPI.

ROS.

PFSH.

Save CancelFinish



Constitutional SystemsEyesEars, Nose, Mouth, ThroatCardiovascularRespiratoryGastrointestinalGenitourinaryMusculoskelatalIntegumentary (skin and/or breast)NeurologicalPsychiatricEndocrineHematologic/LymphaticAllergic/Immunologic

Not Reviewed Reviewed

[Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit][Findings from Prior Visit]

No Change Change

[Problem Pertinent/Extended/Complete]





CC.

HPI.

ROS.

PFSH.

Save CancelFinish


Past History

Family Hx

Past Hx

Past, Family, and/or Social History [Pertinent/Complete]

Entered on MM/DD/YYYYNarrative past history text entered on prior date

History update entered on MM/DD/YYYY

Update text

SocialHx

Guidance from CMS:Past history includes experiences with illnesses, operations, injuries, and treatments

Interval history covers information since the last visit.

History Reviewed and Confirmed

Updates/Interval History





CC.

HPI.

ROS.

PFSH.

Save CancelFinish


Family History

Family Hx

Past Hx


Entered on MM/DD/YYYYNarrative family history text entered on prior date


Update text

SocialHx

Guidance from CMS:Family history includes a review of medical events, diseases, and hereditaryconditions that may place the consumer at risk.








CC.

HPI.

ROS.

PFSH.

Save CancelFinish


Social History

Family Hx

Past Hx


Entered on MM/DD/YYYYNarrative social history text entered on prior date


Update text

Social Hx

Guidance from CMS:Social history includes an age appropriate review of past and current activities.







Constitutional

Musc

Const

Psych

Save Cancel

eCET Vitals

Finish



Sitting Blood PressureStanding Blood PressureSupine Blood PressurePulse RateRespirationTemperatureHeightWeightBody Mass Index

General Appearance

[Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin][Results from Nurse Checkin]

[Problem Focused/Expanded Problem Focused/Detailed/Comprehensive]

Normal Abnormal

Vitals

Not Assessed




Musculoskeletal

Musc

Const

Psych

Save Cancel

eCET AIMS

Finish



Muscle Strength and Tone

Gait and Station


Normal AbnormalNot

Assessed

[Result from AIMS]


[AIMS Due/Overdue from Task List]



Psychiatric

Musc

Const

Psych

Save CancelFinish



Speech

Thought Process

Associations

Abnormal/Psychotic Thoughts

Judgment and Insight

Orientation

Recent and Remote Memory

Attention and Concentration

Language

Fund of Knowledge

Mood and Affect


Normal AbnormalNot

Assessed




Guidance from AMA:Counseling is a discussion with a patient and/or family concerning one or more of the following areas:• Diagnostic results,

impressions, and/or recommended diagnostic studies

• Prognosis• Risks and benefits of

management (treatment) options

• Instructions for management (treatment) and/or follow-up

• Importance of compliance with chosen management (treatment) options

• Risk factor reduction• Patient and family education

MHCD Guidelines:Counseling should be documented with all new medications, at minimum.

Counseling

Save CancelFinish



Minutes spent during session on Counseling



Coordination of Care

Save CancelFinish



Minutes spent during session on Coordination

Description of care coordination, including with whom care was coordinated

Coordination with PCP? No Yes

MHCD Guidelines:Coordination with PCP should be documented at least annually.



Guidance from AMA:Psychotherapy is the treatment of mental illness and behavioral disturbances in which the physician or other qualified health professional, through definitive therapeutic communication, attempts to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personality growth and development.

[It includes] ongoing assessment and adjustment of psychotherapeutic interventions and may include the involvement of family member(s) or others in the treatment process.

Do not report psychotherapy of less than 16 minutes duration.

[Psychotherapy] must be significant and separately identifiable [from the E/M service].

PsychotherapyPsych

Int Compl

Save CancelFinish



Minutes spent during session on Psychotherapy 00



Guidance from AMA:Psychiatric procedures may be reported “with interactive complexity” when at least one of the following is present:1. The need to manage maladaptive

communication (related to, e.g. high anxiety, high reactivity, repeated questions, or disagreement) among participants that complicates delivery of care.

2. Caregiver emotions or behavior that interferes with the caregiver's understanding and ability to assist in the implementation of the treatment plan.

3. Evidence or disclosure of a sentinel event and mandated report to third party with initiation of discussion of the sentinel event and/or report with patient and other visit participants.

4. Use of play equipment, or translator to overcome barriers to interaction between the physician and a patient who:

• Is not fluent in the same language as the physician, or

• Has not developed, or has lost, either expressive or receptive language skills.

Interactive ComplexityPsych

Int Compl

Save CancelFinish



Justification of complexity

Interactive complexity present? No Yes

Data Show if not new



Guidance from CMS:• For a presenting problem with an established diagnosis, the record should reflect whether the problem is: - Improved, well controlled, resolving, or resolved; or - Inadequately controlled, worsening, or failing to change as expected.

MHCD Guidelines:Select New Px this this is the first time you have seen this diagnosis with this consumer; the diagnosis may have been previously treated by another prescriber.

Select Add’l Workup Planned if you have additional diagnostic procedures planned or ordered to make a good differential diagnosis, e.g. psych testing or lab work to rule out physical etiology. Do not select this just for referring the consumer to another physician for future care.

Assessment

Save CancelFinish



Justification for Diagnoses, including Rule-Out Considerations

Diagnoses

[Diagnosis from Axis I/II from Dx Record]

Update Dx or Update GAF Only ?



[Diagnoses from Axis III, IV, V from Dx Record]

Improved Stable WorseningNew Px

Add’lWorkupPlanned

Dx



MHCD Guidelines:In general, risk depends on both the problem and/or the management options selected.

Select High risk if there is:• one or more chronic illness with

severe exacerbation, progression, or side effects;

• Acute or chronic illnesses that pose a threat to life or bodily function;

• Drug therapy requiring intensive monitoring for toxicity

Select Moderate risk if there is:• One or more chronic illnesses with

mild exacerbation, progression, or side effects;

• Two or more stable chronic illnesses;

• An undiagnosed new problem with uncertain prognosis;

• Acute illness with systemic symptoms.

• Prescription drug mangement

Select Low risk for:• Two or more self-limited or minor

problems;• One stable chronic illness• Acute uncomplicated illness• OTC drugs

Select Minimal risk for:• One self-limited or minor problem

Data to be Reviewed

Save Cancel

Done

Finish



Review and/or order clinical lab tests

Review and/or order tests in the radiology section of CPT

Review and/or order tests in the medicine section of CPT

Discussion of test results with performing physician

Decision to obtain old records and/or obtain history from someone other than consumer

Review and summarization of old records and/or obtaining history from someone other than consumer and/or discussion of case with another health care provider

Independent visualization of image, tracing, or specimen itself (not simply review report)

Description of above selected elements

Assessment of Risk

[Dropbox with Minimal, Low, Moderate, High]

Data

Dx



Save CancelFinish



Plan of Care

[Active Medication from OrderConnect]



Referrals, next appointments, and other follow-up

Agency Medications

Add Another Med

[Non-Agency Medication from OrderConnect]



Non-Agency Medications

Add Another Med

Reload OrderConnect

X

X

X

X

X

X



Save CancelFinish


Select the desired E/M Code from the list of allowable codes

[Calculated code][Next lower code][Next lower code][etc]

[Regular Event Screen (like RestateSAL)]



Save CancelFinish

Sign

Report screen. Make all the other screens’ content pretty for printing

Documents

Evaluation and Management Note The E/M note should be launched when the user attempts to reconcile a planned event with a service code of 309 E/M Service