health information system-current procedual terminology meaning?

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Method for computing current procedural terminology codes from
physician generated documentation United States Patent 5483443 A
process is disclosed for calculating a Current Procedural Terminology
("CPT") code from input received from a physician or other medical
professional. The physician is prompted with lists of choices
corresponding to a patient's medical status. The physician makes
selections from these lists which are then input into a computer. The
computer then determines intermediate codes from the physician's
selections. After the physician has completed entering selections, the
computer then calculates a final CPT code for reimbursement purposes
based on the previously calculated intermediate codes. US Patent
References:
System and method for correlating medical procedures and medical
billing codes
Dorne - June, 1994 - 5325293

Apparatus and method for improved estimation of health resource
consumption through use of diagnostic and/or procedure grouping and
severity of illness indicators
Mohlenbrock et al. - May, 1991 - 5018067

Medical reimbursement computer system
Mohlenbrock et al. - May, 1987 - 4667292

Medical diagnostic computer
Sinay - September, 1981 - 4290114

Inventors: Milstein, Bernard A. (Galveston, TX)
Maguire, Nancy J. (Galveston, TX)
Meier, Judith H. (Galveston, TX)
Application Number: 08/226002 Publication Date: 01/09/1996 Filing
Date: 04/08/1994 Export Citation: Click for automatic bibliography
generation Assignee: Promt Medical Systems (Houston, TX)
Primary Class:705/3 International Classes:G06Q10/00; G06F159/00 Field
of Search: 364/413.01, 364/413.02, 364/413.03, 364/401 View Patent
Images:Download PDF 5483443 pdf PDF help Primary Examiner: Mcelheny
Jr., Donald E. Attorney, Agent or Firm: Bardehle & Partners
Claims: We claim:

1. A process for generation of Current Procedural Terminology ("CPT")
codes comprising:

storing historical data in a memory;

comparing the historical data to a set of historical criteria to
define a history code;

storing an examination data in a memory;

comparing the examination data to a set of examination criteria to
define an examination code; storing medical decision making data in a
memory;

comparing the medical decision making data to a set of medical
decision making criteria to define a medical decision making code;

comparing the historical code, the examination code, and the medical
decision making code to a set of final criteria to define a final CPT
code; and displaying the final CPT code.

2. A process as in claim 1 wherein the display occurs on a CRT screen.

3. A process as in claim 1 wherein the display occurs on a printed
page.

4. A process as in claim 1 wherein the CPT code is provided as an
input variable to an accounting program.

5. A process for computing Current Procedural Terminology ("CPT")
codes from documentation generated by a medical professional, said
process comprising:

displaying a set of queries to the medical professional;

receiving input from the medical professional in response to said
queries;

computing a component historical code based on said input and a set of
stored historical criteria;

computing a component examination code based on said input and a set
of stored examination criteria;

computing a component medical decision code based on said input and a
set of stored medical decision criteria;

computing a final CPT code based on said historical code, said
examination code and said medical decision code and a set of stored
patient encounter criteria.

6. A process as in claim 5 wherein said computing a component
historical code comprises weighting said historical code based on the
number of times a historical criterion is met.

7. A process as in claim 5 wherein said computing a component
examination code comprises weighting said examination code based on
the number of times an examination criterion is met.

8. A process as in claim 5 wherein said computing a component medical
decision code comprises weighting said medical decision code based on
the number of times a medical decision criterion is met.

9. A process as in claim 5 wherein said medical decision code further
comprises a number of diagnoses sub-component code, a risk of
complications sub-component code and a complexity of data reviewed
sub-component code.

10. A process as in claim 5 wherein said component historical code,
said component examination code and said component medical decision
code are computed each time input is received.

11. A process as in claim 5 wherein said queries further comprise
textual phrases.

12. A process as in claim 5 wherein said queries are textual
selections related to a medical treatment of a patient.

13. A process as in claim 5 wherein said queries are free of
International Classification of Disease ("ICD") and Diagnosis Related
Group ("DRG") code numbers.

14. A process as in claim 5 wherein said queries comprise diagnostic
lists used in generating a patient's medical record.

15. A process as in claim 5 wherein said input is free of ICD and DRG
code numbers.

Description:

A microfiche appendix is included in this specification as Enhanced
Appendix A. Also included is Enhanced Appendix B containing Decision
Matrix Tables.

BACKGROUND OF THE INVENTION

This invention relates to medical record documentation and calculating
codes from that documentation thereby improving the consistency and
the quality of medical care.

Billing for a physician's services has become increasingly more
complex in recent years. Medicare requires that a code be assigned to
each patient encounter, the interaction between a patient and the
physician, assistant, nurse or other health care provider to evaluate
the patient's medical problem. These codes encompass the complexity of
the problem evaluated, the amount of work required of the physician
and the level of detail required in both the history and physical
portions of the examination. A third-party payor is an organization,
carrier or intermediary that supplies insurance, especially health
insurance (including Medicare), to individuals.

The American Medical Association in conjunction with the Health Care
Financing Administration (HCFA) has developed a system of codes for
the purpose of describing physician work for medical and surgical
procedures, diagnostic tests, laboratory studies, and other physician
medical services rendered to clients. This system of codes is
generally referred to as Current Procedural Terminology, or CPT,
codes. They provide a uniform language that details medical, surgical,
and diagnostic services utilized by physicians to communicate to
third-party payors the services that are rendered.

The Evaluation and Maintenance (E/M) codes are a sub-set of the CPT
codes that are used to describe the patient encounter in an office,
hospital or other setting. E/M codes are used to describe the level of
care (work) a physician renders to a patient. The three key components
of an E/M code are history, examination and medical decision making
preformed by the provider during an encounter. E/M and CPT codes are
revised yearly by the American Medical Association.

The World Health Organization developed a similar method to identify
medical diagnoses, conditions and injuries. These codes are
International Classification of Diseases 9th edition Clinical
Modification (ICD9) codes. They are international codes, unlike the
CPT codes which are national.

To manage this increasing complexity, groups such as Medicare Part B
and independent companies such as the Physician Management Information
Company (PMIC) have developed categorizations of various parts of the
patient encounter. These aids usually take the form of checklists on
letter or legal sized papers. They are often several pages long and
serve to aid the provider in choosing the accurate level of service.

Some individuals have created small (generally 3'×5') cards that some
physicians carry in pockets detailing the levels of service and the
requirements for each level to insure accurate billing. The card has a
general summary of the rules for a particular insurance payor. While
providing easier access for the physician than the full size
checklists or outlines, these cards provide only general guidelines.
Many of the guidelines do not have concrete documentation guidelines.
A physical examination, for example, may range from "problem focused"
to "comprehensive." The more specific descriptions and examples are
found in the CPT manual and several bound texts. These texts may not
be easily accessible during the encounter. Moreover, they may not be
used to verify a code description until after the encounter is over
and the patient has gone home.

Additionally, some professional coders have developed their own plans
for classifying the encounters into the appropriate code. These plans
usually consist of lists or outlines and chart abstractions. They are
applied to the documentation, usually after the encounter is
completed, before billing the claim to the insurance carrier.

CodeLink is a software package developed by Context Software Systems,
Inc. that compares the CPT code typed by the user to the ICD9 code or
codes or vice versa. The two codes are compared based on the medical
necessity established by HCFA. The codes are not generated as part of
the real-time documentation process, but CodeLink is used as a
separate, stand-alone reference after the encounter.

Documation is a software package used for medical documentation and
OcuChart is the ophthalmology specific documentation software. Both
were developed by Documation Inc. This software has a built-in ICD9
coding system. It does not calculate the E/M codes for billing a level
of service.

PRISM is another software package that documents the medical
encounter. It was developed by PRISM Data Systems, Inc. PRISM's
Patient Registration module prints a list of CPT, E/M, and ICD9 codes
selected by the physician. This list is not patient-specific. PRISM
also does not calculate E/M codes or other service codes.

None of the known prior documentation code-linkage approaches are able
to actually accomplish the long-felt needs of: deriving accurate
calculated codes during the documentation process, calculating codes
that are as accurate as possible, and doing this in an easy-to-use
manner for the provider. Once the coding can be accomplished
consistently, the billing process becomes routine. These problems are
not limited to a particular medical specialty, but are common to both
general practitioners as well as specialists and to a growing group of
other limited medical practitioners and insurance payors. Medical
specialists are defined as physicians who have chosen to concentrate
their interest on one of the body systems or other medical groupings.

It is thus an important object of the present invention to provide the
ability to generate codes based on the amount of work performed to
describe the patient encounter. Medicare and other third-party payors
are increasingly relying on a system of codes to describe the patient
encounter. These codes are definable. The original definitions of
these codes are contained in a variety of cumbersome texts. Some
physicians use one of the shortened aids that are sometimes several
pages long. Shorter, pocket sized versions may not completely define
all the coding rules and regulations. Even the smallest method
presents some degree of intrusion during the physician-patient
encounter. The invention incorporates the desired coding scheme into
the documentation of the encounter by the provider of services or
anyone using the invention.

A further object of the invention is consistent coding. Most of the
rules on the checklists and pocket cards are general rules. The
invention incorporates rules for each third-party payor into a series
of criteria. Specific criteria for each code are met or not met. The
codes will then not vary due to differing interpretations. By tying
the definition to the actual documentation, the invention provides a
more reliable means of coding the encounter and a sense of security
for the provider that an accurate code has been billed based on
"medically necessary" guidelines.

Another object of the invention is to provide accurate coding. The
invention allows derived codes such as E/M codes to be measured
objectively. The criteria may be manipulated to give a precise
definition for any code. The codes describing the overall encounter
are more valid. Accuracy is also a factor when assigning procedural
and diagnosis codes like the ICD9 and CPT codes. Human error may
factor into any process where numbers are looked up in one source and
transcribed into another. The system also allows the physician to
select the textual descriptions of terms as an integral part of
documenting the encounter. The descriptions are automatically attached
to the appropriate code number(s).

A further object of the invention is to provide real-time calculations
of the code during the patient encounter. Many of the checklists and
other aids are used by the physician or other coder after the
encounter: history, examination, medical decision making is completed.
The invention calculates the codes as each portion of the encounter is
entered into the documentation system. This concurrent calculation
assures greater accuracy, consistency and is time-efficient for the
physician.

Another object of the invention is to provide additional patient
interaction time for the physician. The physician is freed from many
medical record keeping tasks allowing for more time for interaction
with the patient and family.

Still another object of the invention is linkage of the procedure(s)
performed and diagnosis (why the service was rendered) to determine
medical necessity. While CodeLink compares ICD9 and CPT codes and
determines whether "medically necessity" was established, it does not
determine any of the E/M codes or the ophthalmology codes (both are
subsets of the CPT codes). This invention gathers the ICD9 and CPT
codes during the encounter. This allows the physician or the office
staff to save time by not having to look up each ICD9 or CPT code
number in the ICD9-CM. Additionally, the medical necessity is
determined during the encounter when the procedure is ordered, not
after it is preformed, potentially decreasing the number of claims
disallowed for not meeting the medical necessity criteria.

An additional advantage of the invention is the printing of a
customized summary of the diagnoses, procedures and tests rendered to
the patient, including E/M or established ophthalmology code
calculated during the encounter. PRISM prints a physician-specific
list, but not a patient specific list and does not calculate the E/M
or established ophthalmology codes.

Further objects and advantages of this invention will become apparent
from a consideration of the drawings and ensuing description. It is
further to be understood that many changes and modifications of the
embodiment of the invention as hereinafter described may be had
without departing from the spirit of the invention as defined in the
appended claims.

SUMMARY OF THE INVENTION

This invention allows a physician to record medical data and assign
codes to medical diagnoses while the appropriate code associated with
the encounter is automatically calculated. Additionally, the charges
associated with the code and any other procedural codes are therefore
automatically determined.

A patient encounter may be broken into three key components of
history, examination, and medical decision making. The history portion
usually consists of queries about the patient's current health,
previous problems and any related family or social problems. The
examination component is the actual physical examination by the
physician and any tests or procedures ordered or provided. A third
component, the complexity of the medical decision making, is the
result of the interaction of the history and examination portions of
the encounter and represents the level of difficulty to the physician
for forming a diagnosis and treatment plan(s). The basis for the
invention is the history and examination portions of the patient
encounter and the physician's thought processes and these are broken
into generally accepted segments. The physician selects choices from
extensive lists that become the basis for the patient's medical record
and required documentation.

As each segment of the encounter is completed, credit is given toward
assigning a code which becomes the basis for payment from a
third-party payor. This code calculates in the background during the
encounter based on the physician's documentation of work rendered. The
actual calculation of the code is diagramed in the flow charts shown
in FIGS. 1 to 8. Having determined the component code, i.e. History,
Examination and Medical Decision Making, the final code is calculated
independently (FIG. 9) based upon the amount of time since the last
encounter. The final codes are determined from this comparison to meet
necessary criteria.

The criteria used for each decision point in the flow charts may be
varied allowing the system to be customized for different insurance
carriers, physician preferences or geographic differences. These
criteria could be adjusted due to changing regulations and
interpretations by the American Medical Association, The Health Care
Financing Agency or other payor groups. They may be adjusted via a
criteria entry screen. A set of recommended criteria for various
groups is available. An example of a set of criteria would be: Chief
Complaint--1 entry; Present Illness--1 entry for History-component
Code A, 3 entries for History-component Code B, C, or E; Specialty
Specific Conditions and Diseases--1 entry; Specific Systemic
Diseases--1 entry; Medications--1 entry; Allergies--1 entry; Family
History--1 entry for History-component Codes A, B or C, 2 entries for
History-component Code E; Social History--1 entry for
History-component Code A, B, or C, 2 entries for History-component
Code E; Medical History--1 entry for History-component Code A, B, or
C, 2 entries for History-component Code E; Specialty Specific
Surgery--1 entry for History-component Code A, B, or C, 2 entries for
History-component Code E; Surgical History--1 entry for
History-component Code A, B, or C, 2 entries for History-component
Code E; Systems Review--0 entries for History-component Code A or B, 1
entry for History-component Code C, 15 entries for History-component
Code E; Vision--1 entry; Confrontational Visual Fields--1 entry;
Eyelids--1 entry; Ocular Motility--1 entry; Pupils/Iris--1 entry;
Cornea--1 entry; Anterior Chamber--1 entry; Lens--1 entry; Intraocular
Pressure--1 entry; Retina--1 entry; Optic Disc--1 entry; Criteria
G--meets 8 of 10 criteria (Confrontational Visual Fields, Eyelids,
Ocular Motility, Pupils/Iris, Cornea, Anterior Chamber, Lens,
Intraocular Pressure, Retina, Optic Disc); Criteria H--all of one
sub-group (eyelids, lacrimal, orbit; anterior segment cornea, anterior
chamber, iris, lens, intraocular pressure; optic disc, sensory
function, visual fields); Criteria J--meets 2 of criteria; Criteria K-
meets 1; Data Reviewed--1 entry for Data-reviewed-subcomponent Code D,
2 entries for Data-reviewed-subcomponent Code E; High Risk
Medications--1 entry; Age--less than 5 or over 65, Invasive Office
Procedures--1 entry; High Risk Diagnoses--1 entry; Specific Test
Results--pressure over 20 mm Hg; Present Illness--1 entry for
Management-options-subcomponent Code A or B, 2 entries for
Management-options-subcomponent Code D, 3 entries for
Complexity-subcomponent Code E; Allergies to Specific Medications--1
entry, Current Selected Medications--1 entry for
Management-options-subcomponent Code D, 2 entries for
Management-options-subcomponent Code E; Current Systemic
Medications--1 entry; Specific Family History--1 entry; Specific
Diagnostic Results--vision corrected <20/60; Total Diagnoses--1
Management-options-subcomponent Code A or B, 2 entries for
Management-options-subcomponent Code C or D, 3 entries for
Management-options-subcomponent Code E; Medications Ordered, Cancelled
or Continued--1 entry for Management-options-subcomponent Code B, C or
D, 2 entries for Management-options-subcomponent Code E; Call or
Return Less Than One Week--1 entry; Call or Return Less Than One
Month--1 entry. An example of how the criteria are tied together is
given below.

Additionally the system allows physicians to switch between various
code assignments. For example, currently ophthalmologists are allowed
to use one of two coding systems to describe an encounter to Medicare,
the E/M codes and the Established or Secondary Ophthalmology codes.
Both codes in this invention are calculated simultaneously allowing a
physician to merely switch back and forth between the codes. In the
same way, they could change between a variety of payors and their
differing requirements.

BRIEF DESCRIPTION OF THE DRAWINGS

Now referring to the drawings:

FIGS. 1A-1C show flow chart of the History component;

FIG. 2 is a flow chart of the Examination component;

FIG. 3 is a flow chart of the Medical Decision Making component;

FIGS. 4A-4C show a flow chart of the Number of Diagnoses or Management
Options sub-component of Medical Decision Making;

FIG. 5 is a flow chart of the Complexity of Data Reviewed
sub-component of Medical Decision Making

FIG. 6 is a flow chart of the Risk of Complication and/or Morbidity or
Morality sub-component of Medical Decision Making;

FIG. 7 is a flow chart of the Overall New Patient Code;

FIG. 8 is a flow chart of the Established or Secondary Ophthalmology
Code;

FIG. 9 is a flow chart of the General Rule Engine.

DESCRIPTION OF EMBODIMENTS OF THE INVENTION

All portions of the patient encounter may be entered into the
invention in any order. A physician may also enter one portion of a
section and then return and enter additional information in that
section. The FIGURES are presented in the order that many patient
encounters are conducted. Definitionally, a component is one of the
major areas of the encounter (e.g., History, Examination or Medical
Decision Making), a sub-component is an additional division of a
component, and a section is a specifically defined area of the
encounter (e.g., chief complaint or eyelid). In the flow charts, the
rectangular-shaped process boxes identify the sections. The diamond
shaped decision boxes identify where the criteria for a particular
section are tested.

Each section has various criteria associated with it. Whether or not
each criterion is met determines the associated code. As new
information is added to each section, the code is recalculated
according to the criteria-set (i.e. the criteria for a particular
third-party payor) currently being used.

FIGS. 1A-1C show the History component of the encounter. There are
twelve sections in the History component. They include: a Chief
Complaint section 104, a Present Illness section 108, a Specialty
Specific Conditions and Diseases section 114, a Specific Systemic
Diseases section 118, a Medications section 124, an Allergies section
128, a Family History section 132, a Social History section 136, a
Medical History section 140, a Specialty Specific Surgery section 144,
a Surgical History section 148, and finally a Systems Review section
152.

FIG. 2 details the Examination component of the encounter. There are
10 sections in the ocular examination. They include: a confrontational
visual fields section, an eyelids section, an ocular motility section,
a pupils/iris section, a cornea section, an anterior chamber section,
a lens section, an intraocular pressure section, a retina section, and
an optic disc section. Like the History component, each section of the
Examination component may be completed in any order.

The Medical Decision Making component (FIG. 3) consists of three
sub-components, Number of Diagnoses or Management Options (FIGS.
4A-4C), Complexity of Data Reviewed (FIG. 5), and Risk of
Complications and/or Morbidity or Mortality (FIG. 6). The Medical
Decision Making component is illustrated in FIG. 3. The code from each
sub-component (302, 304, and 306) is compared to the criteria and the
appropriate MDM-component code selected. The sub-components of Medical
Decision Making use sections from the History and Examination
components as well as additional information.

The Number of Diagnoses or Management Options sub-component is shown
in FIGS. 4A-4C. The sections in this sub-component include: Present
Illness 108, Allergies 128, an Allergies to Specific Medications
section, Current Selected Medications and Current Systemic
Medications. Additional sections are a Specific Family Diseases
section (a subset of Family History 132) and a Specific Diagnostic
Results section. A calculated section, Total Diagnoses, is also
included. It is followed by a Tests and Procedures Ordered section and
a Medications Ordered, Cancelled, or Continued section. Finally, a
Call or Return Less Than One Month section and a Call or Return Less
Than One Week section are included. A final section, Management
Options Increment, compares the counter to the criteria and determines
the Management-options-subcomponent code. Complexity of Data Reviewed,
FIG. 5, is the next sub-component of the Medical Decision Making
component. A Data Reviewed section 506 determines the
Data-reviewed-subcomponent Code for this sub-component.

The Risk of Complications and/or Morbidity or Mortality is illustrated
in FIG. 6. A High Risk Medications section 608 (a subset of
Medications 124) is followed by an Age section 614, an Invasive Office
Procedures section 620 (a subset of Tests and Procedures Ordered 434)
and a High Risk Diagnoses section 626. A Specific Test Results section
632 also is included. A final section, Risk Counter 636, compares the
counter to the criteria and determines the Risk-subcomponent Code for
this subcomponent.

The Established or Secondary Ophthalmology Code, FIG. 8, calculates a
separate type of code used by ophthalmologists. It consists of Present
Illness, a Tonometry section, Medications Ordered, Canceled or
Continued, and Tests and Procedures Ordered. It also includes an
Anterior section and a Posterior section.

OPERATION OF INVENTION

The final code for new patients is determined by the component codes
calculated from the History component 158, the Examination component
224 and the Medical Decision Making component 320 as shown in FIG. 7.
Each component code (History, Examination and Medical Decision Making)
is determined in the process illustrated by FIGS. 1A-1C, 2 and 3.
These three component codes are compared according to the criteria and
the final code 718 is determined. If the three component codes
(calculated from History, Examination, and Medical Decision Making)
are identical 710, the Final Code is the component code 716. If the
three component codes are different 712, the lowest component code is
the Final Code 718. This process is repeated whenever any of the
History, Examination and Medical Decision Making component codes
change. It continues until the patient encounter is over and the
medical record for that encounter has been sealed.

A different set of criteria may be available for each insurance payor.
Each criterion is linked to a particular section. A section may have
several criteria, but each criterion is only associated with a
particular section.

The manner for determining the code associated with the
History-component, FIG. 1 is that as elements are added to each
section, the elements are checked to see if specific criteria are met.
After the criteria are reviewed the History-component code is
calculated. This process is repeated with each addition in all
sections of the history component-criteria are checked and
History-component codes recalculated. In this component, as in all the
components, the actual order that each section is completed is
irrelevant; the order is presented as a series of decision points
rather than an order of entry.

Chief Complaint 104 is gathered. If this section meets the specified
criteria 106, Present Illness 108 is gathered. If Chief Complaint 104
does not meet the criteria, History-component Code F 112 is obtained.
If Present Illness 110 does not meet the criteria, History-component
Code F 112 is obtained. If Present Illness 110 meets the criteria,
then Specialty Specific Conditions and Diseases 114 is investigated
along with Specific Systemic Diseases 118. If the criteria is not met
for either section 116 or 120, History-component Code A 122 will
result. If the criteria for sections 116 and 120 are met, the
History-component code could be assigned History-component Code E 160.
If the criteria for sections 116 or 120 are met, Medications section
124 is checked. If the criteria 126 are met, Allergies 128 are
collected. If the criteria for Medications 126 are not met,
History-component Code B 156 ensues. History-component Code B 156 also
follows if the criteria for Allergies 130 are not satisfied. When the
criteria associated with Allergies 130 is met, information about
Family History 132 and Social History 136 is compared to their
respective criterion (134 and 138). If neither of these criteria are
met, History-component Code B 156 will be determined. If both criteria
134 and 138 are met, the History-component code could be assigned
History-component Code E 160. When criteria for Family History 134 or
Social History 138 are fulfilled, information about Medical History
140, Specialty Specific Surgery 144 and Surgical History 148 are
gathered. If the criteria for none of the three sections (142, 146, or
150) are met, History-component Code B 156 results. When the criteria
for at least one of sections 142, 146 or 150 are met, information
about Systems Review 152 are checked. If criterion 154 is criterion k,
History-component Code B 156 results, but if criterion 154 is l,
History-component Code C 158 results. If criterion 154 is m, and the
criteria for both 116 and 120 and the criteria for both Family History
134 and Social History 138 as well as the criteria for Medical History
142, Specialty Specific Surgery 146 and Surgical History 150, the
result is History-component Code E 160. The resulting Code 162 is
carried to process illustrated in FIG. 7, Overall New Patient Code.

The manner for determining the code associated with the Examination
component, FIG. 2 is that as elements are added to each section, the
elements are checked to see if specific criteria are met. After the
criteria are reviewed the Examination-component code is calculated.
This process is repeated with each addition in all sections of the
Examination component.

Vision 204 is the first section of the Examination component and if
the criteria 204 is not met, Examination-component Code F 242 results.
If the criteria 204 associated with Vision is met, the Visual Field
section 206 is gathered. The Eyelids section 208 is gathered. The
Ocular Motility section 210 and the Pupils/Iris section 212 are
collected. Next, Cornea 214 is gathered. Anterior Chamber 216 is
obtained Then Lens 218 is collected. Intraocular Pressure 220 is
gathered followed by Retina 222. The final section collected is Optic
Disc 224. If the Criteria G 226 is met, the resulting
examination-component code is Examination-component Code E 234. If
Criteria G is not met, but the Criteria H 228 is met, the
examination-component code is Examination-component Code C 236. If
Criteria H is not met, but the Criteria J 230 is met, the
examination-component code is Examination-component Code B 238. If
Criteria J is not met and Criteria K is met, examination-component
Code A 240 is assigned. Examination-component Code F 242 is assigned
if Criteria K is not met. The resulting examination-component code is
carried into the process illustrated by FIG. 7, Overall New Patient
Code as 244. The manner for determining the MDM-component code
associated with the Medical Decision Making (FIG. 3) component is that
as elements are added to each section of each sub-component (302, 304
or 306), the elements of the sub-component are checked to see if
specific criteria are met. After the criteria are reviewed the code
for the sub-component is calculated. This process is repeated with
each addition in all sections of all sub-components of the Medical
Decision Making component. The MDM-component code associated with
Medical Decision Making is recalculated whenever any of the
sub-component codes have been revised. The resulting MDM-component
Code 320 is carried into the process illustrated by FIG. 7, Overall
New Patient Code.

The first sub-component is Number of Diagnoses or Management Options,
FIG. 4. Present Illness 108 is gathered and if it meets the criteria
476, the counter 404 is incremented. Allergies 128 is then collected
and the counter 408 is incremented if the criteria 478 are met.
Allergies to Specific Medications 410 is gathered and the counter 412
is incremented if the criteria 458 are met. Next, Current Selected
Medications 414 is obtained. The counter 416 is incremented if the
criteria 460 are met. Then, Current Systemic Medications 418 is
collected and if the criteria 462 are met, the counter 420 is
incremented. Specific Family History 422 is obtained next. If the
criteria 464 are met, the counter 424 is incremented. Specific
Diagnostic Results 426 is collected and the counter 428 is incremented
if the criteria 466 are met. Then Total Diagnoses 430 is gathered and
if the criteria 468 are met, the counter 432 is incremented. Tests and
Procedures Ordered 434 are gathered and if the criteria 470 are met
the counter 436 is incremented. Medications Ordered, Cancelled or
Continued 438 is obtained next. The counter 440 is incremented if the
criteria 472 are met. Then Call or Return Less Than One Week 442 is
gathered and if the criteria 474 are met, the counter 444 is
incremented. Then, Call or Return Less Than One Month 474 is gathered
and if the criteria 446 are met, the counter 448 is incremented. The
next section is Management Options Counter 450. Finally, the
Management Options Counter 450 determines the
Data-reviewed-subcomponent Code (452, 453, 454 or 456) based on the
associated criteria. The Data-reviewed-subcomponent Code 452, 453, 454
or 456 is carried into the process illustrated by Medical Decision
Making, FIG. 3 at 455.

The second sub-component of Medical Decision Making is Complexity of
Data Reviewed, FIG. 5. The Data Reviewed section 504 is gathered. If
criterion x is met, Management-options-subcomponent Code C 508
results. Meeting criterion y determines
Management-options-subcomponent Code D 510 and
Management-options-subcomponent Code E 512 results from meeting
criterion z. The Management-options-subcomponent Code 514 is entered
into the process illustrated by FIG. 3.

The final sub-component of Medical Decision Making is illustrated in
FIG. 6, Risk of Complications and/or Morbidity or Mortality. High Risk
Medications 606 is collected. If the criteria 608 are met, the counter
610 is incremented. Age 612 is gathered and the counter 616 is
incremented if the criteria 614 are met. Invasive Office Procedures
618 is collected and if the criteria 620 are met, the counter 622 is
incremented. High Risk Diagnoses 624 is obtained. The counter 628 is
incremented if the criteria 626 are met. Specific Test Results 630 is
collected and if the criteria 632 is met the counter 634 is
incremented. Finally, the Risk Counter 636 determines the
Risk-subcomponent code based on the associated criteria. If criterion
w is met, Risk-subcomponent Code B 638 results. Risk-subcomponent Code
C 640 occurs if criterion x is met and Risk-subcomponent Code D 642 if
criterion y is met. Risk-subcomponent Code E 644 follows from
criterion z. The Risk-subcomponent Code 646 is carried into the
process illustrated by FIG. 3, Medical Decision Making at 306.

The manner for determining the code associated with the Established or
Secondary Ophthalmology Code, FIG. 8, is that as elements are added to
each section, the elements are checked to see if specific criteria are
met. After the criteria are reviewed, the Established or Secondary
Ophthalmology code is calculated. This process is repeated with each
addition in all sections of the Established or Secondary Ophthalmology
Code.

First, Present Illness 108 is gathered. If the criteria 806 are not
met, Established or Secondary Ophthalmology Code L 334 is obtained. If
the criteria 806 are met, Tonometry 808 is collected. Established or
Secondary Ophthalmology Code L 334 is also obtained if criteria 810
are not met. If the Tonometry criteria 810 are met, Medications
Ordered, Cancelled or Continued 438 is collected and if the criteria
818 are met, Anterior 824 is gathered. If the 818 criteria are not
met, Tests and Procedures Ordered 434 are gathered. If the criteria
822 are not met, Established or Secondary Ophthalmology Code L 834 is
obtained. If the criteria 822 are met, Anterior 824 and Posterior 826
are gathered. If the criteria 828 and 830 are both met, Established or
Secondary Ophthalmology Code N 838 is obtained. If the criteria are
met for Anterior 828 or Posterior 830, Established or Secondary
Ophthalmology Code M 836 is obtained and if the criteria are met for
neither Anterior 828 nor Posterior 830, Established or Secondary
Ophthalmology Code L 834 is obtained.

This system has the ability to immediately convert between the
Established or Secondary Ophthalmology Codes and the E/M Codes for a
particular encounter. Simply by selecting the code option, the
physician can change between these two codes.

FIG. 9 describes a General Rules Engine. When the encounter begins, it
is determined if the process is done (904). If the process is done,
the process is ended. If the process is not done, the predefined
process of either History (910), Examination (912) or Medical Decision
Making (914) are investigated.

Facts may have a number associated with them for consideration by an
expert system engine. These rules are expressed using logic. The
engine then takes these facts and applies rules to see which
conclusions may be established. The rule engine in this invention also
considers the number of times a particular rule is met. An example of
this occurs in the History component where in order to obtain
History-component Code E 15 of the Systems Review areas must be
addressed, but only 1 area for History-component Code C. This could be
addressed using a very large set of rules with a conventional rule
engine. To address only the History-component Code C portion, for a
convention engine exponentially more rules would have to be stated
than the one rule for the proposed engine. The proposed engine would
use a much smaller rule base since all the facts would not have to be
explicitly specified.

EXAMPLES

To illustrate the above components, several examples are cited. These
examples use ophthalmology as a specialty. The Medicare set of
criteria is also used since it is a wide-spread third-party payor,
especially in ophthalmology. The invention is not specialty specific.
It can be applied to any medical specialty with ease. Additionally, by
changing the criteria-set it can be tailored to various payors'
systems.

The first example concerns a 24 year old female requesting an
examination for glasses. This causes an entry in box 104, chief
complaint; and item 612. She has never been to this physician before
and is a new patient. Her vision is blurred at a distance and she has
trouble reading street signs, especially at night. She also has been
having headaches for the past two weeks. These three statements cause
an entry in box 108 and the criteria 110 are met. She currently wears
contact lenses and has for three years and this information creates an
entry in box 114, specialty specific conditions and diseases. She is
currently taking antibiotics for a sinus infection, triggering box 124
and has no allergies, filling box 128. Her mother had cataracts which
were removed and replaced with an intraocular implant and her paternal
grandfather had glaucoma, filling box 132, family history. She states
she has never had any ocular surgeries (144) and has a medical history
of sinusitis (142). She denies having any migraines, hypertension or
diabetes (152). On further questioning it was learned she sees "halos"
when driving at night from oncoming car headlights. Her headaches are
dull and aching and she usually wakes up with headaches in the morning
(152). Using the system, the History-component code for this patient
would be History-component Code C (158).

Her vision (204) is then checked and found to be OD 20/60 and OS
20/80. The refraction manifest is OD -3.00+1.00×90, OS -3.00+1.00×90.
Confrontational visual fields (206) are normal. The lens (218) is
normal with no indications of cataracts. Her intraocular pressure
(220) is 18 mm Hg OU by applanation. Her retinas (222) are normal. The
disc (224) is normal with no cupping. The Anterior Chamber (216) and
iris (212) are normal. Eyelids (208) are normal. The resulting
Examination-component code for this patient would be
Examination-component Code E (234).

The Number of Diagnoses or Management Options sub-component would
result in Management-options-subcomponent Code C (454). No High Risk
Medications (606) were being used. She does not meet the Age (614)
criteria since at 24 she is under 65 and over 5 years old. Her
physician did not perform any Invasive Office Procedures (618) and no
High Risk Diagnoses (626) were noted. The patient's intraocular
pressure was less than 20 mm Hg and so the Specific Test Results (632)
criteria is not met. The Risk of Complications and/or Morbidity or
Mortality sub-component would be Risk-subcomponent Code B (638) and
the Complexity of Data Reviewed sub-component would yield
Management-options-subcomponent Code C (510) based on the amount of
data reviewed (506). The Medical Decision Making component's code
would be MDM-component Code C (320) since the middle of the three
subcomponent codes (454, 638, and 510) is a MDM-component Code C.

The resulting final code for this patient would be a Final Code C
(714) since the lowest component code of the three components (158,
234, and 320) was a Component Code C.

The Established or Secondary Ophthalmology code would be Established
or Secondary Ophthalmology Code N (838).

CONCLUSIONS, RAMIFICATIONS AND SCOPE

The invention described here is a system for converting medical
documentation into a variety of codes, providing an effective and
consistent means for calculating a basis for reimbursement. The system
is consistent and by prompting physicians to provide information in a
reproducible form, will significantly improve the quality of medical
care as well as provide a means to gauge the effectiveness of various
treatment regimens.

There are currently a number of medical documentation systems that
provide a means for documentation; but there are none that enable a
physician to gauge the extent of his work effort in a consistent
manner. Moreover, the other documentation systems do not calculate a
concrete code to describe the more abstract effort levels expended
during the patient encounter.

By tying the system to the documentation process, additional material
such as code books are not needed and physicians will be encouraged to
extensively document their work because of the ease with which they
can accomplish this. Coding the diagnoses during the real-time of the
encounter will improve the quality of the coding and the information
gathered.

It is our belief that by improving the information produced by a
medical documentation system, the invention will encourage physicians
to use such a system and thereby improve the quality of medical care
for all.

ENHANCED APPENDIX B

 

Decislon Matrix - New Patient 99202 99201 Expanded 99205 Problem
Problem 99203 99204 Compre- Focused Focused Detailed Comprehensive
hensive

 

HISTORY
Chief Complaint x x x x x
Present Illness Vision/Function
Requires a
99202-99205 require a minimum of 3
statements
Pain minimum of 1-2
in any of these sub-menus
(Vision/Function, Pain,
Appearance statements in
Appearance, Pre-Existing Condition,
Trauma)
Pre-Existing Condition
any of these
Trauma sub-menus
Severity of (does not drive E&M code)
2 3 or 4
4 4 or 5 4 or 5
Presenting
Prob
Past Ocular History
Ocular Problems/Diseases x/-- x/-- x/--
Ocular Surgeries x/-- x/-- x/--
Oculo-Systemic Diseases x/-- x/-- x/--
Allergies x/-- x/-- x/-- x/-- x/--
Current Medications
Ocular x/-- x/-- x/-- x/-- x/--
Systemic x/-- x/-- x/--
Medical History Oculo-Systemic Diseases x/-- x/--
Medical History x/-- x/--
Surgical History x/-- x/--
Systems Review x/-- x/--
Family History Ocular Problems/Diseases x/-- x/-- x/--
Ocular Surgeries x/-- x/-- x/--
Oculo-Systemic Diseases x/-- x/-- x/--
Social History x/-- x/-- x/--

Decision Matrix - New Patient 99202 99201 Expanded Problem Problem
99203 99204 99205 Focused Focused Detailed Comprehensive Comprehensive

 

EXAM
Vision Uncorrected 1 entry in 1
1 entry in
1 entry in
1 entry in 1
1 entry in 1 of
With Correction
of these
1 of these
1 of these
these these
Pinhole sub-menus
sub-menus
sub-menus
sub-menus
sub-menus
Refraction/
Present Glasses
Keratometry
Present Contacts
(refractions do not
Refraction - Dry
drive the code)
Retinoscopy
Refraction - Manifest
Refraction - Cycloplegic
Retinopathy
Refraction - Cycloplegic
Manifest
Keratometry
Tonometry/Pupil
Applanation 1 entry for
2 or more
1 entry for
1 entry for both
Schiotz both eyes in
entries for
eyes in 1 of
eyes in 1 of the
Pnuemotonometer 1 of the
both eyes in 1
Tonometry
Tonometry
Tonopen Tonometry,
of the sub-menus
sub-menus
Handheld Anterior or
Tonometry,
Serial Posterior
Anterior or
Pupil sub-menus
Posterior
Anterior Exam
Motility sub-menus
1 entry for
1 entry for both
Lids eyes in 1 of
eyes in 1 of the
Conjunctiva Anterior
Anterior Exam
Cornea sub-menus
sub-menus
Anterior Chamber
Iris
Lens
Gonioscopy
Posterior Exam
Vitreous 1 entry for
1 entry for both
Optic Disc eyes in 1 of
eyes in 1 of the
Vessels Posterior
Posterior Exam
Macula sub-menus
sub-menus
Fundus
Office Tests
(certain high risk tests
will affect medical
decision making)

 

 

I. Number of Diagnoses or Management Options

 

# #
Sentences Allergies
# Current
# Current
# Family
Correctd
# Oculo- Considered/
in Present # of to Ocular
Ocular
Systemic
Ocular
Vision
Systemic
# Ocular
Ruled-Out
Illness Allergies
Meds Meds Meds Diseases
<20/60
Conditions
Diagnoses
Diagnoses

 

Straight
Forward
1 0 0 0 0 0 0 0 1 entry in 1 of these
2
Low
Complexity
1 1 0 0 0 0 0 0 2 entries in these 2
Moderate
Complexity
2 1 1 1 1 1 1 2 entries in these 3
High
Complexity
3 2 1 2 1 1 1 3 entries in these

1. Meds ---- # Tests & Ordered, Call/ Call/ Total Procedures Cancelled, Return Return Diags Ordered Continued <1 month <1 week SUM Code

 

Straight 99201
Forward
1 0 0 0 0 2 99202
Low
Complexity
2 0 1 1 0 6 99203
Moderate
Complexity
2 1 1 1 1 14 99204
High
Complexity
3 1 2 1 1 19 99205

 

i.e. 20/61,62,63 etc. ----The Total Diagnoses column does not impact
matrix.

 

II. Amount &/or Complexity of Data Reviewed # of Data Reviewed Code

 

Straight 99201
Forward 0 99202
Low
Complexity 0 99203
Moderate
Complexity 1 99204
High
Complexity 2 99205

III. Risk of Complications and/or Morbidity or Mortality # High Risk #
High Intra-Ocular # High Risk <age 5 or Ofc Procs Risk Pressure
Medications >age 65 (Invasive) Diags >20 SUM Code

 

Stright 99201
Forward
0 0 0 0 0 0 99202
Low
Complexity
0 0 0 0 1 1 99203
Moderate
Complexity
1 1 1 1 1 3-- 99204
High
Complexity
1 1 1 1 1 4-- 99205

 

--any 3 or 4

 

Present Prescribe/Cancel Tests/Procedures Illness Tonometry Anterior
Posterior Medications Ordered

 

92002
1 1 1 or 1 1 or 1
92004
1 1 1 1 1 or 1

 

 

Decislon Matrix - Established Patient 99213 99212 Expanded Problem
Problem 99214 99215 Focused Focused Detailed Comprehensive

 

HISTORY
Chief Complaint x x x x
Present Illness Vision/Function
Requires a
99213-99215 require a minimum
of 3
Pain minimum of 1-2
statements in any of these
sub-menus
Appearance statements in
(Vision/Function, Pain,
Appearance,
Pre-Existing Condition
any of these
Pre-Existing Condition,
Trauma)
Trauma sub-menus
Severity of Presenting Prob
(does not drive E&M code)
2 3 or 4 4 4 or 5
Past Ocular History Ocular Problems/Diseases x/-- x/--
Ocular Surgeries x/-- x/--
Oculo-Systemic Diseases x/-- x/--
Allergies x/-- x/-- x/-- x/--
Current Medications Ocular x/-- x/-- x/-- x/--
Systemic x/-- x/--
Medical History Oculo-Systemic Diseases x/--
Medical History x/--
Surgical History x/--
Systems Review x/--
Family History Ocular Problems/Diseases x/-- x/--
Ocular Surgeries x/-- x/--
Oculo-Systemic Diseases x/-- x/--
Social History x/-- x/--

 

NOTE: 99212-99215 require two of the three major components (history,
exam, medical decision making). 99215 requires a Comprehensive History
OR a Comprehensive Exam + High Complexity Decision Making. The
Established Patient codes (99212-99215) are different from the New
Patient codes as follows: New Patient codes require three of the three
major components; Established Patient codes require two of the three.

 

Decision Matrix - Established Patient

 

EXAM
Vision Uncorrected 1 entry in 1
1 entry in 1
1 entry in
1 entry in 1
With Correction of these
of these
of these
of these
Pinhole sub-menus
sub-menus
sub-menus
sub-menus
Refraction/Keratometry
Present Glasses
Present Contacts
(refractions do not drive
Refraction - Dry Retinoscopy
the code) Refraction - Manifest
Refraction - Cycloplegic Retinopathy
Refraction - Cycloplegic Manifest
Keratometry
Tonometry/Pupil
Applanation 1 entry for
2 or more
1 entry for both
Schiotz both eyes in
entries
eyes in 1 of the
Pnuemotonometer 1 of the
both eyes in
Tonometry
Tonopen Tonometry,
of the sub-menus
Handheld Anterior or
Tonometry,
Serial Posterior
Anterior or
Pupil sub-menus
Posterior
Anterior Exam
Motility sub-menus
1 entry for both
Lids eyes in 1 of the
Conjunctiva Anterior Exam
Cornea sub-menus
Anterior Chamber
Iris
Lens
Gonioscopy
Posterior Exam
Vitreous 1 entry for both
Optic Disc eyes in 1 of the
Vessels Posterior Exam
Macula sub-menus
Fundus
Office Tests (certain high risk tests
will affect medical
decision making)

I. Number of Diagnoses or Management Options

 

# #
Sentences Allergies
# Current
# Current
# Family
Correctd
# Oculo- Considered/
in Present # of to Ocular
Ocular
Systemic
Ocular
Vision
Systemic
# Ocular
Ruled-Out
Illness Allergies
Meds Meds Meds Diseases
<20/60
Conditions
Diagnoses
Diagnoses

 

Straight
Forward
1 0 0 0 0 0 0 0 1 entry in 1 of these
2
Low
Complexity
1 1 0 0 0 0 0 0 2 entries in these 2
Moderate
Complexity
2 1 1 1 1 1 1 2 entries in these 3
High
Complexity
3 2 1 2 1 1 1 3 entries in these

 

1. Meds ---- # Tests & Ordered, Call/ Call/ Total Procedures Cancelled, Return Return Diags Ordered Continued <1 month <1 week SUM Code

 

Straight
Forward
1 0 0 0 0 2 99212
Low
Complexity
2 0 1 1 0 6 99213
Moderate
Complexity
2 1 1 1 1 14 99214
High
Complexity
3 1 2 1 1 19 99215

 

i.e. 20/61,62,63 etc. ----The Total Diagnoses column does not impact
matrix.

 

II. Amount &/or Complexity of Data Reviewed # of Data Reviewed Code

 

Straight
Forward 0 99212
Low
Complexity 0 99213
Moderate
Complexity 1 99214
High
Complexity 2 99215

III. Risk of Complications and/or Morbidity or Mortality # High Risk #
High Intra-Ocular # High Risk <age 5 or Ofc Procs Risk Pressure
Medications >age 65 (Invasive) Diags >20 SUM Code

 

Stright
Forward
0 0 0 0 0 0 99212
Low
Complexity
0 0 0 0 1 1 99213
Moderate
Complexity
1 1 1 1 1 3-- 99214
High
Complexity
1 1 1 1 1 4-- 99215

 

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