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Time In: (includes all time spent with patient)
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Time Out: (includes all time spent with patient)
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Total Duration E&M Portion (chief complaint)
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Requirements and Reminders
• • •
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Chronic Care Management Acknowledge
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Meds Reviewed (MIPS)
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Yes - Dementia Caregiver Education Provided (MIPS)
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No dementia education provided (MIPS)
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Yes- Dementia safety counseling
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No dementia safety education
|
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Extended nonF2F PrePost 31 min (99358)
• • •
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DON"T USE THIS ---Extended nonF2F PrePost next 45 min (99359)
• • •
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Previsit activities
• • •
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Previsit minutes and date
|
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Postvisit activities
• • •
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Post Visit Minutes and date
|
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*****Pre Post Comments
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Billing E&M based on:
|
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Billing for Time? - Care & Coordination time > 50%
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***If billing for time then: C & C activities
• • •
|
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***Comments about C&C - required
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E and M codes - Pick 1
|
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DONT USE ---TCM Code 7 days (99496 - document contact in 48 hrs)
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DONT USE ---TCM Code 14 days (99495 - contact within 48 hours)
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TCM 7 day Date of Discharge
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TCM 14 day Date of Discharge
|
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Dr Price Piksesville Med Director
|
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Home Level 5 - NEW - 75 minutes - 99345
|
ALF Level 5 - NEW - 75 minutes - 99328
|
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Home Level 4 - NEW - 60 minutes -99344
|
ALF Level 4 - NEW - 60 minutes -99327
|
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Home Level 3 - NEW - 45 minutes - 99343
|
ALF Level 3 - NEW - 45 minutes - 99326
|
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Home Level 2 - NEW - 30 minutes - 99342
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ALF Level 2 - NEW - 30 minutes - 99325
|
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Home Level 1 - NEW - 20 minutes - 99341
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ALF Level 1 - NEW - 20 minutes -99324
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Home Level 4 - EST - 60 minutes - 99350
|
ALF Level 4 - EST - 60 minutes - 99337
|
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Home Level 3 - EST - 40 minutes - 99349
|
ALF Level 3 - EST - 40 minutes - 99336
|
|
Home Level 2 - EST
|
ALF Level 2 - EST
|
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Extended Visit Codes
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Extra time over max level visit (30 min - 99354)
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Extra time over max level visit (30 min - 99355)
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Additional Codes
|
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Care Plan Origination Date - G0506 (one time only)
|
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ACP 99497- (DNR/MOLST)first 16 min
|
CP - 99498 - DNR/MOLST next 44 min
|
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DNR status
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End of Life Discussion with:
• • •
|
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Explanation of Discussion/Filled out form?
|
Minutes with ACP discussion
|
|
Annual wellness visit performed (G0439)
|
|
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Mini Mental Status Performed (attached template pending)
|
MMSE score (use attached template pending)
|
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Motorized wheelchair paperwork (G0372)
|
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Urine Dip done
|
UDIP results
|
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Smoking Cessation - 3 to 9 min - 99406
|
****Smoking cessation minutes - low
|
|
Smoking Cessation 10 or more minutes - 99407
|
*** Required Smoking Cessation minutes
|
|
Wound Debridement
|
Debridement Comments
|
|
Cerumen Disempaction
|
Reason for Cerumen Disempaction
• • •
|
|
Tb test
|
Tb comments
|
|
Stool guaic
|
Guiac results:
|
|
CKD 4 or more
|
|
|
***2018 Flu Vaccine QUADRIVALENT from CCM and given
|
Flu Vaccine Comments
|
|
|
|
|
Intramuscular Flu Injection (supplied by other)
|
|
|
Other Intramuscular Injection (supplied by other)
|
What injected?
|
|
Patient refused flu vaccine for 2017-2018
|
|
|
|
|
|
New Yes / No
|
|
|
ISTAT done? (use macro for results)
|
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|
|
|
|
DME orders (height and weight required)
|
|
|
(ADMIN ONLY) DME order cosigned by MD G0454
|
MD Verification of F2F for DME - G0454
|
|
Hospital Bed Order (E0260) (with mattress)
|
Hospital bed because (pick 2)
• • •
|
|
Hospital Bed Order (E0261) - frame only
|
Hospital bed because (pick 2)
• • •
|
|
Hospital Bed Accessories - Trapeze (E0910)
|
Trapeze Reasons
• • •
|
|
Hospital Bed Accessory - Bed Rails (Full length) (E0310)
|
Hospital Bed Accessory - Bed Rails (Half length) (E0305))
|
|
Level 1 surface (gel overlay E0185)
|
Level 1 surface selections - Gel
• • •
|
|
Level 1 surface (Alternating Pressure Pad E0181)
|
Level 1 surface selections - APP
• • •
|
|
Low Air Loss Mattress (E0277)
|
Low Airloss requirements (E0277) - choose one
• • •
|
|
Standard Wheelchair Order
|
Wheelchair reasons (pick 1) - patient cannot
• • •
|
|
K2 wheelchair (hemi) - with seat to floor 17.5 or lower (use foot for propel)
|
Wheelchair K2 reasons (pick 1) - patient cannot
• • •
|
|
K3 wheelchair - lightweight
|
Wheelchair K3 reasons (pick 1) - patient cannot
• • •
|
|
K4 wheelchair - high strength lightweight
|
Wheelchair K4 reasons (pick 1) - patient cannot
• • •
|
|
High back reclining wheelchair with headrest
|
High Back reclining
• • •
|
|
3 in 1 commode
|
|
|
Hoyer Lift
|
|
|
Nebulizers (best to have private pay...)
|
|
|
|
|
|
Oxygen ordered
|
|
|
O2 at rest (qualify if less than 89%)
|
6 minute stress test if performed - 94620
|
|
O2 with exertion
|
|
|
W exertion on O2 (only if gets better w O2)
|
|
|
|
|
|
Medical Decision Making
|
|
|
Hx/Discussion w Other Med Providers (2 points)
• • •
|
Other med provider Comment:
|
|
Hx/Discussion w non-health person: (1 point)
• • •
|
Other med provider Comment:
|
|
Old Medical Records Request (1 point)
• • •
|
Non health provider comments
|
|
Old Med Records Summarized (1 points)
|
Medical Records Reviewed (1 point)
|
|
Home Health Recommendation(1 point)
• • •
|
Home health req comments
|
|
Hospice Recommendation (1 point)
• • •
|
Hospice request comments
|
|
Other Care Circle Recs (1 point)
• • •
|
Care circle request comments:
|
|
Labs requested (1 point)
• • •
|
Lab request comment
|
|
Radiology studies ordered: (1 point)
• • •
|
Radiology Request Comments
|
|
Pulse ox performed with value in chart (1 point)
|
|
|
Prescribed a new medication (1 point)
|
|
|
Prescribed a controlled substance (1 point)
|
|
|
EKG ordered
|
EKG comments
|
|
EKG reviewed
|
|
|
AMA (use Macro)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Quality Measures required for DOCS Only
|
|
|
Tobacco Cessation Intervention (0028b)
|
|
|
2014 Flu Vacc (G8482/3/4) for NQF0024
|
|
