Software device to facilitate creation of medical records, medical letters, and medical information for billing purposes

• US 7,801,740 B1
• Filed: 09/22/1998
• Issued: 09/21/2010
• Est. Priority Date: 09/22/1998
• Status: Expired due to Fees

• Current Assignee: Tamarind Systems LLC
• Original Assignee: Tamarind Systems LLC
• Inventors: Lesser, Ronald Peter
• Primary Examiner(s): Morgan; Robert W
• Application Number:
  US09/157,998
• Time in Patent Office: 4,382 Days
• Field of Search: 705 2- 3, 705/4
• US Class Current: 705/2
• CPC Class Codes: G06Q 10/10 Office automation; Time management
• CPC Class Codes: G06Q 30/04 Billing or invoicing
• CPC Class Codes: G16H 10/60 for patient-specific data, e.g. for electronic patient records

Abstract

A method is described which simplifies, automates and organizes the creation of notes and correspondence and also, by performing the calculations needed to determine the appropriate billing codes, provides documentation for billing purposes. It also assists the health care worker in determining the proper billing code. An embodiment of this to facilitate the creation of documents in the setting of patient care is described. The use of this for medical records is particularly of importance because of recent government (Heath Care and Finance Administration, or HCFA) regulations. The embodiment also allows one to enter information into a patient database at the same time that one is entering clinical information for the purposes of clinical care documentation. The database could be for clinical care, quality assurance, or research purposes. The embodiment describes how this can be achieved at the time that a service is delivered, for example when a health care worker sees a patient. Because the data is entered at the time of service, time is saved, and the information is more accurate. Although the embodiment describes a use in health care, this could be used in any industry. The invention allows one to enter information about patients using a combination of checklists, menus, and fill in the blank formats. The invention could use any handheld or desktop computer. Data entry also could be accomplished using scanner-enabled paper forms similar to those used by questionnaires or by tests such as the Scholastic Aptitude Test, with the user filling in the appropriate circles or other spaces to indicate the answer.

Claims

1. A method of calculating a billing code for a patient encounter that complies with the requirements of the United States Health Care Financing Administration (HCFA) (now known as Centers for Medicare and Medicaid Services (CMS)) (collectively HCFA/CMS), including the steps of:

(a) providing an electronic computer or scannable form;

(b) prompting a user via said electronic computer or scannable form to collect information regarding said patient encounter, said information including at least certain information relevant to calculating said billing code;

(c) collecting and recording said information regarding said patient encounter using said electronic computer or said scannable form into a data base or data table; and

(d) using said electronic computer or said scannable form to electronically derive an appropriate HCFA/CMS billing code from said collected information.

2. The method of claim 1, in which said electronic computer or scannable form is provided in the form of a handheld computer with a touch screen interface, and said recording step includes entering the information in real time into said electronic computer via said touch screen interface.

3. The method of claim 1 or claim 2, wherein said electronic computer is at least one of desktop computer, computer terminal, laptop computer, handheld computer, handheld device, voice recognition device, voice recognition software, and scannable forms.

4. The method of claim 1, wherein said billing code is based at least in part on comparing a total patient encounter time and a total patient counseling time.

5. The method of claim 1 further including storing patient counseling information and patient care information, and using said stored information for clinical care, prescriptions, counseling materials, educational materials, correspondence, quality assurance, billing, research, historical tracking and/or analyzing.

6. The method of claim 1, further including:

computer-readable patient-administered information forms for obtaining certain data related to patient care or to Health Care Financing Administration (HCFA) (now known and Centers for Medicare and Medicaid Services (CMS)) (collectively HCFA/CMS) requirements.

7. Apparatus for compiling medical data and generating a billing code based on said medical data and being consistent with payer mandates, comprising:

electronic means for displaying items for evaluation of a patient during a patient encounter, said items being at least sufficient to support billing requirements imposed by said payer mandates;

data forms for collecting and storing patient responses and/or user findings regarding history, examination, assessment, counseling, or decision occurring as a result of said patient encounter;

means for storing and accessing said patient responses and/or said user findings;

an algorithm for linking and comparing said patient responses and/or said user findings with values for billing, procedure, treatment, counseling and/or documentation requirements; and

calculating means for deriving a resultant code based in part on said algorithm.

8. The apparatus of claim 7, wherein said resultant code is an evaluation and management code to be used in a claim and for submitting to a payer.

9. The apparatus of claim 7, further comprising a timer for tracking total time and patient counseling time during said patient encounter, and algorithm for computing the percent of total time used for counseling.

10. The apparatus of claim 8, wherein said billing codes are Health Care Financing Administration (HCFA) (now known as Centers for Medicare and Medicaid Services (CMS)) (collectively HCFA/CMS) codes.

11. The apparatus of claim 7, wherein said billing codes are insurance requirement codes.

12. The apparatus of claim 8, 9, 10 or 11 wherein said electronic means comprising one of desktop computer, computer terminal, laptop computer, handheld computer, handheld device, voice recognition device, voice recognition software, handwriting recognition device, or hand writing recognition software.

13. The apparatus of claim 7, wherein said electronic means comprises at least one of desktop computer, computer terminal, laptop computer, handheld computer, handheld device, voice recognition device, voice recognition software, and scannable paper forms.

14. The apparatus of claim 7, wherein said billing code is based at least in part on comparing a total patient encounter time and a total patient counseling time, and determining said billing code based upon said comparison.

15. The apparatus of claim 7 or 8, wherein said data includes patient counseling information and patient care information.

16. The apparatus of claim 7, further including using said stored patient responses and/or user findings for clinical care, prescriptions, counseling materials, educational materials, correspondence, quality assurance, billing, research, historical tracking and/or analyzing.

17. An integrated electronic system for conducting a medical interview of a patient and contemporaneously compiling medical data and calculating an appropriate Evaluation and Management billing code based on that interview, including:

electronic means including;

a prompting means for generating real-time prompts to prompt an interviewer to make a series of inquiries for eliciting responses from the patient during a patient encounter, said series of inquiries and said responses including at least sufficient details to support billing requirements imposed by payer mandates, said series of inquiries including individual data elements needed to calculate or derive the Evaluation and Management billing code,

said prompting means further including;

a calculating means for calculating further prompting for inquiries regarding the patient using at least some of the preceding responses;

a guiding means for guiding the interviewer during said interaction with the patient;

a reminding means to remind the interviewer regarding specific points of inquiry relevant to further examination of that patient; and

a soliciting means to solicit underlying information usable for calculating a description of the medical services being provided, said underlying information comprising details of a patient history, details of a patient examination and/or details of medical decision making regarding a patient diagnosis, details of medical tests to describe, diagnose and/or treat the patient, information used for clinical research, information used for quality assurance, and/or information used to compile patient care data base information;

the electronic means further including;

a recording means for recording said responses or other related information corresponding to the series of inquiries; and

a calculating means using information including said recorded responses to derive the Evaluation and Management billing code, said billing code complying with the billing requirements imposed by said payer mandates.

18. The system of claim 17, wherein the billing code is based at least in part on comparing a total patient encounter time and a total patient counseling time.

19. The system of claim 17, where said billing code is based on billing requirements imposed by the United States Health Care Financing Administration (now known as Centers for Medicare and Medicaid Services (CMS)) codes.

20. The system of claim 17, in which said electronic means comprises a handheld computer with a touch screen interface, said interface facilitating the recording of information in real time.

21. The system of claim 17, wherein said electronic means comprising one of desktop computer, computer terminal, laptop computer, handheld computer, handheld device, voice recognition device, voice recognition software, handwriting recognition device, hand writing recognition software or scannable form.

22. An apparatus for assisting a user in conducting a patient encounter, said patient encounter comprising inquiry, examination, assessment, counseling, or decision regarding said patient, storing data regarding said patient encounter, and generating a billing code based on said patient encounter data, including:

prompting means for reminding the user to enter individual data elements, wherein said data elements comprise data needed to indicate the type of patient encounter, to document what was found or what occurred during said patient encounter, and/or to comply with requirements for calculation of said billing code specific for said type of patient encounter;

inputting means for recording said patient encounter data;

data storage means for preserving said patient encounter data;

calculating means for using said data regarding said patient encounter to derive for the user said billing code, said billing code complying with billing requirements imposed by payer mandates for said type of patient encounter; and

data access means wherein items preserved by said data storage means and results of said calculating means can be viewed, analyzed, or revised.

23. A method for assisting a user in conducting a patient encounter, said patient encounter comprising inquiry, examination, assessment, counseling, or decision regarding said patient, storing data regarding said patient encounter, and generating a billing code based on said patient encounter data, including:

providing the apparatus of claim 22;

said method further including at least one of the following steps;

the apparatus prompting the user to enter individual data elements, wherein said data elements comprise data needed to indicate the type of patient encounter, to document what was found or what occurred during said patient encounter, or to comply with requirements for calculation of said billing code specific for said type of patient encounter;

the user inputting said patient encounter data;

electronically storing said patient encounter data;

calculating from said data regarding said patient encounter to derive for the user said billing code, said billing code complying with billing requirements imposed by payer mandates for said type of patient encounter; and

accessing said data and/or said results of said calculating step for viewing, communicating, analyzing, or revising same.

24. The method of claim 23, wherein said billing code is derived based on rules set forth in the Documentation Guidelines for Evaluation and Management Services billing code of the Health Care Financing Administration (HCFA), now called Centers for Medicare &

Medicaid Services (CMS).

25. The method of claim 23, said step of electronically storing said patient encounter data including storing patient counseling information and patient care information.

26. The method of claim 23 or claim 25, further including using said stored patient encounter data for clinical care, prescriptions, counseling materials, educational materials, correspondence, quality assurance, billing, research, historical tracking and/or analyzing.

27. The apparatus of claim 22, said data access means including means for preparing communications regarding results of said patient encounter and said calculating means, said communications including documentation regarding what was found or what occurred during said evaluation, documentation sufficient to support said billing code, and/or communications to other health care providers.

28. The apparatus of claim 22, said data access means including means for facilitating use of said information in connection with clinical research, quality control, patient care data base information, clinical notes, clinical counseling notes, or correspondence.

29. The apparatus of claim 22, wherein said calculating means comprises a timer for tracking total time of patient encounter and total counseling time during said patient encounter, and an algorithm for comparing said total time of said patient encounter and said total counseling time during said patient encounter, and determining whether said billing code should be based upon said comparison.

30. The apparatus of claim 22, wherein said electronic means comprises a personal computer, desktop computer, laptop computer, network server, handheld computing device, portable computing device, or scannable form.

31. The apparatus of claim 22, wherein said data storage means comprises a data base or data tables.

32. The apparatus of claim 31, wherein said data base or data tables are modifiable as needed.

33. The apparatus of claim 22, further comprising an adding means, wherein said user can add free text to said data elements, said free text entered by said user by means comprising voice dictation, voice recognition software, handwriting, or direct keyed entry.

34. The apparatus of claim 22, wherein said prompting means is customizable to accommodate needs of specific medical practices.

35. The apparatus of claim 22, wherein said prompting means is modifiable to accommodate changes in said payer mandates and clinical practice.

36. The apparatus of claim 22, wherein said prompting means is customizable to accommodate the needs of medical encounters, medical practices, or users.

37. The apparatus of claim 22, wherein said data access means is customizable according to needs of said medical encounter or of said user.