Electronic template medical records coding system

• US 6,529,876 B1
• Filed: 03/26/1999
• Issued: 03/04/2003
• Est. Priority Date: 03/26/1999
• Status: Expired due to Fees

• Current Assignee: Neil W. Rawlins, Stephen H. Dart
• Original Assignee: Neil W. Rawlins, Stephen H. Dart
• Inventors: Dart, Stephen H., Rawlins, Neil W.
• Primary Examiner(s): RIMELL, SAMUEL G
• Application Number:
  US09/277,857
• Time in Patent Office: 1,439 Days
• Field of Search: 705/2, 705/3, 705/4
• US Class Current: 705/4
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 40/08 Insurance
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A method and a computer program and computer apparatus for use by health care providers for the production of accurate billing coding for care rendered. The invention established the process, the data gathering and documentation required of a provider in determining and documenting correct Evaluation and Management CPT code(E&M code or E&M coding) required for agency reimbursement for care delivered. This invention is directed to a computer and computer program wherein a computer program requires a computer to perform a complete audit of E&M coding prior to billing thus ensuring compliance with statutory and regulatory requirements. The system enables providers to comply with statutory and regulatory reporting requirements demonstrating the meeting of Federal and State statutory and regulatory standards prerequisite to payment to the medical provider for health care delivered.

Claims

1. A method for using a computer to facilitate E&

M coding by a medical provider of a patient encounter comprising;

A. inputting into the computer a code selecting An electronic template specific to a type of patient encounter;

B. acquiring data prompted by the electronic template for the specific type of patient encounter for a specific patient encounter;

C. inputting into the computer the data acquired for the specific type of patient encounter for the specific patient encounter;

D. outputting an audit of the inputted data acquired for the specific patient encounter;

E. outputting a Preliminary E&

M code;

F. inputting into the computer modifying variables for the specific patient encounter;

G. outputting a Final E&

M code;

the method in which the step of inputting into the computer a code selecting an electronic template specific to a type of patient encounter further comprises;

H. inputting into the computer a set of electronic templates and an electronic template menu;

and in which the step of acquiring data prompted by the electronic template for the specific type of patient encounter comprises;

I. examining at least one aspect of the patient encounter,

and in which the step of inputting into the computer the data acquired for the specific type of patient encounter for the specific patient encounter comprises;

J. inputting into the computer data acquired from the examination of the at least one aspect of the patient encounter;

and in which the step of outputting an audit of the inputted data acquired for the specific patient encounter comprises;

K. displaying and comparing the data inputted into the computer with the data required to be acquired, in examining at least one aspect of the patient encounter,

and in which the step of outputting a Preliminary E&

M code comprises;

L. displaying the data inputted into the computer and requiring the inputting of an acknowledgment of complete data acquisition and data inputting;

and in which the step of inputting into the computer modifying variables for the specific patient encounter comprises;

M. identifying the modifying variables pertinent to the specific type of patient encounter;

identifying the modifying variables pertinent to the specific patient encounter;

and in which the step of outputting a Final E&

M code comprises;

N. displaying the data inputted into the computer, requiring the inputting of an acknowledgment of complete data acquisition and data inputting, storing by means, the Final E&

M code.

2. The method of claim 1 further comprising:

A. the set of electronic templates comprising an electronic template for each type of patient encounter;

requesting the electronic template menu;

selecting by key stroke, mouse, touch pad or other menu selection means, the electronic template specific to the type of patient encounter;

B. examining at the at least one aspect of the patient encounter, by one or a plurality of patient encounter entities, as prompted by the selected electronic template;

C. displaying aid comparing the data inputted into the computer with the data required to be acquired as prompted by the selected electronic template and requiring the inputting of an acknowledgment of complete data acquisition and data inputting for the at least one aspect of the patient encounter;

D. displaying the data inputted into the computer and requiring the inputting of an acknowledgment of complete data acquisition and data inputting; and

in which the step of inputting into the computer modifying variables for the specific patient encounter comprises;

E. selecting the modifying variables pertinent to the specific patient encounter;

inputting data representing the selected modifying variables into the computer;

F. displaying the data inputted into the computer, requiring the inputting of an acknowledgment of complete data acquisition and data inputting, storing by means, the Final E&

M code.

3. The method of claim 2 in which the one or a plurality of patient encounter entities includes nurse station software interface, reception interface, check-in interface, check-out interface and provider interface.

4. The method of claim 2 in which the selection of the electronic template is from the group electronic templates for types of patient encounters including general multi-system examination;

cardiovascular examination;

ear, nose and throat examination;

eye examination;

genitourinary examination;

hematologic/lymphatic/immunologic examination;

musculoskeletal examination, neurological examination;

psychiatric examination;

respiratory examination; and

skin examination.

5. A method for using a computer to facilitate E&

M coding by a medical provider of a patient encounter comprising;

A. inputting into the computer a code selecting one or a plurality of electronic template specific to one or a plurality of types of patient encounters;

B. acquiring data prompted by the one or a plurality of electronic templates for the specific one or a plurality of types of patient encounter for a specific patient encounter;

C inputting into the computer the data acquired for the one or a plurality of specific types of patient encounter for the specific patient encounter;

D. outputting one or a plurality of audits of the inputted data acquired for the specific patient encounter;

E. outputting one or a plurality of Preliminary E&

M codes;

F. inputting into the computer one or a plurality of modifying variables for the specific patient encounter;

G. outputting one or a plurality of Final E&

M codes;

the method of inputting into the computer a code selecting one or a plurality of electronic templates specific to one or a plurality of types of patient encounters further comprises;

H. inputting into the computer a set of electronic templates and an electronic template menu;

requesting the electronic template menu;

and in which the step of acquiring data prompted by the one or a plurality of electronic templates for the one or a plurality of specific type of patient encounter comprises;

I. examining at least one aspect of the patient encounter,

and in which the step of inputting into the computer the data acquired for the one or a plurality of specific types of patient encounter for the specific patient encounter comprises;

J. inputting into the computer data acquired from the examination of the at least one aspect of tie patient encounter;

and in which the step of outputting one or a plurality of audits of the inputted data acquired for the specific patient encounter comprises;

K. displaying and comparing the data inputted into the computer with the data required to be acquired, in examining at least one aspect of the patient encounter;

and in which the step of outputting one or a plurality of Preliminary E&

M codes comprises;

L. displaying the data inputted into the computer and requiring the inputting of one or a plurality of acknowledgments of complete data acquisition and data inputting;

and in which the step of inputting into the computer one or a plurality of modifying variables for the specific patient encounter comprises;

M. identifying the one or a plurality of modifying variables pertinent to the one or a plurality of specific types of patient encounter;

identifying the one or a plurality of modifying variables pertinent to the specific patient encounter;

and in which the step of outputting one or a plurality of Final E&

M codes comprises;

N. displaying the data inputted into the computer, requiring the inputting of one or a plurality of acknowledgments of complete data acquisition and data inputting, storing by means, the one or a plurality of Final E&

M codes.

6. The method of claim 5 further comprising:

A. inputting into the computer the set of electronic templates comprising an electronic template for each type of patient encounter, selecting by key stroke, mouse, touch pad or other menu selection means, one or a plurality of electronic template specific to the type of patient encounter;

B. examining the at least one aspect of the patient encounter by one or a plurality of patient encounter entities, as prompted by the one or a plurality of the selected electronic templates;

C. displaying and comparing the data inputted into the computer with the data required to be acquired as prompted by the selected one or a plurality of electronic templates and requiring the inputting of one or a plurality of acknowledgments of complete data acquisition and data inputting for the at the least one aspect of the patient encounter;

D. selecting the one or a plurality of modifying variables pertinent to the specific patient encounter;

inputting data representing the selected one or a plurality of modifying variables into the computer.

7. The method of claim 6 in which the one or a plurality of patient encounter entities includes nurse station software interface, reception interface, check-in interface, check-out interface and provider interface.

8. The method of claim 6 in which the selection of the one or a plurality of electronic templates is from the group electronic templates for types of patient encounters including general multi-system examination;

cardiovascular examination;

ear, nose and throat examination;

eye examination;

genitourinary examination;

hematologic/lymphatic/immunologic examination;

musculoskeletal examination, neurological examination;

psychiatric examination;

respiratory examination; and

skin examination.

9. The method of claim 6 in which the step of acquiring data prompted by the electronic template for the specific type of patient encounter comprises:

A. conducting an examination of at least a history component, a physical component and a medical decision component, by one or a plurality of patient encounter entities, as prompted by the selected electronic template;

and in which the step of inputting into the computer the data acquired for the specific type of patient encounter for the specific patient encounter comprises;

B. inputting into the computer data acquired from the examination of the at least a history component, a physical component and a medical decision component for the patient encounter;

and in which the step of outputting an audit of the inputted data acquired for the specific patient encounter comprises;

D. displaying and comparing the data inputted into the computer with the data required to be acquired, for the at least a history component, a physical component and a medical decision component for the patient encounter, as prompted by the selected electronic template and requiring the inputting of an acknowledgment of complete data acquisition and data inputting for the at least a history component, a physical component and a medical decision component of the patient encounter;

E. outputting a Preliminary E&

M code;

F. inputting modifying variables;

G. outputting a Final E&

M code.

10. The method of claim 9 in which the step of acquiring data prompted by the electronic template for the at least a history component comprises:

A. taking, at a patient encounter, the Chief Complaint/History of Present Illness(CCHPI);

taking the Past Family Social History(PFSH) and making a Review of Systems(ROS);

and in which the step of acquiring data prompted by the electronic template for the at least a physical component comprises;

B. conducting a physical exam;

and in which the step of acquiring data prompted by the electronic template for the at least a medical decision component comprises;

C. making a data evaluation;

making a diagnosis;

making a risk assessment;

and in which the step of inputting into the computer the data acquired from the examination of the at least a history component;

D. inputting the data of the taking of the CCHPI;

inputting the data of the taking of the PFSH, inputting the data of the making of the ROS;

and in which the step of inputting into the computer the data acquired from the examination of the at least a physical component;

F. inputting the data of the making of the physical exam;

and in which the step of inputting into the computer the data acquired the examination of the at least a medical decision component;

H. inputting the data from making the data evaluation;

inputting the data from making the diagnosis;

inputting the data from making the risk assessment;

and in which the step of outputting an audit of the data for the at least a history component;

I. displaying and comparing the data inputted into the computer with the data required to be acquired as prompted by the selected electronic template, for the at least a history component from the taking of the CCHPI;

for the taking of the PFSH; and

for the making of the ROS;

requiring the inputting of an acknowledgment of complete data acquisition and data inputting for the taking of the CCHPI producing a CCHPI Code Level;

for the taking of the PFSH producing a PFSH Code Level; and

for the making of the ROS producing a ROS Code Level;

and in which the step of outputting an audit of the data for the at least a physical component;

J. displaying and comparing the data inputted into the computer with the data required to be acquired as prompted by the selected electronic template, for the at least a physical component from the making of the physical exam;

requiring the inputting of an acknowledgment of complete data acquisition and data inputting for the making of the physical exam producing a physical code level;

and in which the step of outputting an audit of the data for the at least a medical decision component;

K. displaying and comparing the data inputted into the computer with the data required to be acquired as prompted by the selected electronic template, for the at least a medical decision component from the making of the data evaluation;

from the making of the diagnosis, and from the making of the risk assessment;

requiring the inputting of an acknowledgment of complete data acquisition and data inputting for the making of the data evaluation producing a data evaluation code level, for the making of the diagnosis producing a diagnosis code level, and the making of the risk assessment producing a risk assessment code level;

from the making of the physical exam producing a physical code level;

and in which the step of outputting a Preliminary E&

M code comprises;

L. combining the CCHPI code level, the PFSH code level and the ROS code level producing the Lowest Code Level and the History Code Level;

combining the data evaluation code level, the diagnosis code level and the risk assessment code level producing the Level of Highest Two Code Levels and the Medical Decision Code Level;

combining the History Code Level, the Physical Code Level and the Medical Decision Code Level producing the Patient Encounter Category;

selecting from the Patient Encounter Category the Lowest of 3 Code Levels or the Highest Two Code Levels producing the Preliminary E&

M code.