Data processing: financial – business practice – management – or co – Automated electrical financial or business practice or... – Insurance
Reexamination Certificate
1999-03-26
2003-03-04
Rimell, Sam (Department: 2175)
Data processing: financial, business practice, management, or co
Automated electrical financial or business practice or...
Insurance
C705S002000
Reexamination Certificate
active
06529876
ABSTRACT:
FIELD OF THE INVENTION
The present invention relates generally to a method and apparatus for electronic coding of medical services rendered to patients and particularly to a method of coding medical services rendered to patients for compliance with Federal and State statutory and regulatory requirements for the avoidance of fraud and abuse in application for reimbursement from governmental agencies for services rendered pursuant to regulations including Health Care Financing, Medicare and Department of Health and Human Services regulations.
BACKGROUND OF THE INVENTION
Medical providers are eligible for the receipt of payments from governmental agencies upon providing certain care. Providers are required by statute and regulation to meet particular standards, in reporting and requesting payment, for the purpose of avoiding the commitment of fraud and abuse in requesting and receiving such payment. The provider must properly and correctly code multiple aspects of an encounter with a patient to form the basis for meeting regulatory requirements required for payment. Incorrect coding may likely result in noncompliance with laws or regulations such as the Federal False Claims Act (31 USC 3729), the Health Insurance Portability and Accountability Act (HIPAA), Stark I and II and similar Federal and State laws enacted to protect against fraudulent claims for reimbursement for the providing of health care. Medical providers are thus exposed to criminal and civil penalties relating to compliance with regulatory and statutory requirements.
The medical encounter documentation and coding is increasingly complex. Health Care Financing and Medicare rules require documentation of multiple items for every patient seen. For example, there are likely at least 20 items to be documented for each patient encounter and now, for some care, more than 85 items to be documented.. It is ever more difficult for the provider to remember all of the necessary individual documentation items and to document them appropriately. Increases in staffing has been recommended as a means of addressing the burden of correct coding to insure the submission of reimbursement requests which comply with regulatory requirements. However, steps directed to accurate pre-billing audits have left the human element in place and leaving the provider with the difficult burden of correctly and accurately recalling and interrelating each item required to be documented for each patient. The provider is required to expend additional time, remain exposed to the hazard of forgetting an item for the patient and being subjected to civil and criminal sanctions as well as experiencing the increased cost associated with the pre-audit process.
Due to the complexity of, potential for error in Evaluation and Management Coding (E&M coding) and the potential severity of penalty for noncompliance, many providers deliberately under-code patient encounters resulting in a loss of revenue to the provider. Some estimate that as many as 80% of providers under-code from fear of unintentional noncompliance and resulting legal action. Guides exist for use by providers including “A Blueprint For Documenting Your E&M Services”, Conomikes Medicare Hotline, November 1997, Vol. 7, Number 1 revised 1998 and St. Anthony's “Guide to Evaluation and Management Coding and Documentation”, Third Edition. Disclosures are provided herewith in an Information Disclosure Statement in accordance with 37 CFR 1.97.
SUMMARY OF THE INVENTION
The preferred embodiment of the invention provides a method and apparatus to maximize efficiency and accuracy for the provider in determining and documenting correct Evaluation and Management CPT code(E&M code or E&M coding) as required for agency reimbursement for health care delivered. Evaluation and Management (E&M) services are divided into broad categories such as office visits, hospital visits, and consultations. Most of the categories are further divided into two or more subcategories of E&M services. There are two subcategories of office visits including new and established patient and two subcategories of hospital visits including initial and subsequent. The subcategories of E&M services are further classified into levels of E&M services that are identified by specific codes. This classification is important because the nature of physician work varies by type of service, place of service and the patient's status. The basic format of the levels of E&M services is the same for most categories. First, a unique code number is listed. Second, the place and or type of service is specified, for example, office consultation. Third, the content of the service is defined, for example, comprehensive history and comprehensive examination. Fourth, the nature of the presenting problem(s) usually associated with a given level is described. Fifth, the time typically required to provide the service is specified. The levels of E&M services include examinations, evaluations, treatments, conferences with or concerning patients, preventive pediatric and adult health supervision, and similar medical services, such as the determination of the need and or location for appropriate care. Medical screening includes the history, examination, and medical decision-making required to determine the need and or location for appropriate care and treatment of the patient. The levels of E&M services encompass the wide variations in skill, effort, time, responsibility and medical knowledge required for the prevention or diagnosis and treatment of illness or injury and the promotion of optimal health. Each level of E&M services may be used by all medical care providers for the generation of an E&M code representing the level of E&M services rendered for each patient encounter.
This method and apparatus is directed to an electronic or computer base wherein a computer directed by a computer program performs a complete audit of E&M coding prior to billing thus ensuring compliance with statutory and regulatory requirements. The present invention prompts the provider to acquire and document data specifically required for the medical evaluation and, ultimately, the billing for professional services for each different type of patient encounter. The invention effectuates the provider's actions necessary to meet audit requirements. The present invention is therefore a highly effective system in effecting the required bilateral interaction of the provider with both the patient and the E&M coding requirements of each specific type of patient encounter.
The preferred embodiment of the present invention is the establishment of a unique electronic exam template for each specific type of E&M service or patient encounter. The unique template prompts the provider in the acquisition of data peculiar to the specific type of patient encounter as dictated both by standards of medical care and as required by statutory and regulatory standards of E&M code requirements for billing and reporting to regulatory agencies. The preferred embodiment of the invention is the method of use of the electronic exam template as the basic user interface component of the system. A template or form, specific to the particular type of patient encounter, is displayed on a computer screen which contains text fields, drop-down lists, check boxes and graphics. An exam builder utility provides the capabilities necessary to define a dynamic rules base necessary to automatically code the correct E&M code appropriate for the patient encounter. This E&M code is used for billing purposes and directly affects the physician reimbursements from insurance and managed care organizations.
In one embodiment of this invention, the provider, by use of exam builder utility programs, can produce exam templates having characteristics relating to that provider's specific medical practice or preferences.
An exam template is comprised of a logical related set of systems. These systems are created with the exam builder utility allowing the provider to create a set of questions and response areas to cover a specific s
Dart Stephen H.
Rawlins Neil W.
Ivey Floyd E.
Liebler Ivey & Connor
Rimell Sam
LandOfFree
Electronic template medical records coding system does not yet have a rating. At this time, there are no reviews or comments for this patent.
If you have personal experience with Electronic template medical records coding system, we encourage you to share that experience with our LandOfFree.com community. Your opinion is very important and Electronic template medical records coding system will most certainly appreciate the feedback.
Profile ID: LFUS-PAI-O-3083898