HMC/UWMC ED Sample Dot Phrase Templates Version June 2017 Contact UW EM Chiefs with questions () 9/6/17 GENERAL CONCEPTS OF DOCUMENTATION IN EM AT HMC/UWMC There are different documentation requirements for different levels of billing (level 1 billing reflects lowest level of complexity/physician time/involvement; level 5 represents highest level of complexity/time/involvement). HPI – Level 1-3 (one element) Level 4-5 (four elements) ROS (Please do not use the word when describing) – “points” 1 not required – Level 2-3 one system (not required if problem pertinent +/- documented in HPI) – Level 4 2 systems – Level 5 10+ systems – Physical Exam Level 1 one system – Level 2-3 2 systems – Level 4 5 systems – Level 5 8 systems – High Acuity caveat documentation-- it is acceptable to use these phrases when appropriate if you are unable to complete portions of the HPI or PE: unable to obtain history due to … unable to perform full exam due to (crashed to OR, Cath lab, etc) … Please tailor your specific ROS and Physical Exam documentation to reflect exactly what you asked / did/ saw! As part of your MDM, please include the differential diagnoses that you considered. MDM coding is based on - Number of diagnosis and management options Chart reviewed (indicate in MDM that records/chart reviewed and notable for/summarized as follows….) Risk SAMPLE ROS DOT PHRASES Example statements for ROS (pick whichever systems you actually reviewed): 3/14 Review of Systems completed and negative except as stated above in the HPI (Systems reviewed: Resp, CV, GI)
HMC/UWMC ED Sample Dot Phrase Templates Version June 2017 Contact UW EM Chiefs with questions () 9/6/17 GENERAL CONCEPTS OF DOCUMENTATION IN EM AT HMC/UWMC There are different documentation requirements for different levels of billing (level 1 billing reflects lowest level of complexity/physician time/involvement; level 5 represents highest level of complexity/time/involvement). HPI – Level 1-3 (one element) Level 4-5 (four elements) ROS – (Please do not use the word “points” when describing) 1 – not required Level 2-3 – one system (not required if problem pertinent +/- documented in HPI) Level 4 – 2 systems Level 5 – 10+ systems Physical Exam Level 1 – one system Level 2-3 – 2 systems Level 4 – 5 systems Level 5 – 8 systems High Acuity caveat documentation-- it is acceptable to use these phrases when appropriate if you are unable to complete portions of the HPI or PE: unable to obtain history due to … unable to perform full exam due to … (crashed to OR, Cath lab, etc) Please tailor your specific ROS and Physical Exam documentation to reflect exactly what you asked / did/ saw! As part of your MDM, please include the differential diagnoses that you considered. MDM coding is based on - Number of diagnosis and management options Chart reviewed (indicate in MDM that records/chart reviewed and notable for/summarized as follows….) Risk SAMPLE ROS DOT PHRASES Example statements for ROS (pick whichever systems you actually reviewed): 3/14 Review of Systems completed and negative except as stated above in the HPI (Systems reviewed: Resp, CV, GI)