At its core, intervals is simple, yet powerful time tracking and task management software with intelligent reporting to make informed decisions based on your time. Jensen, md, cpc developed this content to introduce physicians and coders to the basic concepts of em coding and documentation. First, looking at the cpt definitions for those categories of codes, all are defined as requiring an interval history. The story must have a beginning, some development, and an ending to adequately describe the em of the patients presenting problems.
Second, go back to the documentation guidelines themselves and see the definition of an interval history. Medical record documentation is required to record pertinent facts, findings, and observations about an individuals health history including past and present illnesses, examinations, tests, treatments, and outcomes. Use intervals for a week and it will reveal valuable insights into where your efforts are going. Cpt coding and em documentation training resources alameda. The use of one emr software product versus another is not relevant. If the documentation includes a statement that the patient did well overnight without recurring symptoms, this would be sufficient. Many types of progress notes can be generated in icanotes. I am now being told that i can find the interval history for a subsequent encounter. What is meant by problemfocused interval history or detail interval history. Med check progress notes, group therapy notes, counseling notes, nursing notes, case management notes, and more. Documentation of the history element of an em service tells a story about an illness, and how it has affected a patient. May we utilize em codes that are not in our programs ru such as snf em codes.
What does it mean when a code requires an interval history. Optimize your use of the interval 2000 by referencing nk sports tech support documents. What documentation is required for the history portion of subsequent hospital visits. Interval 2000 product documentation from the manufacturer javascript seems to be disabled in your browser.
This illustrates something important about the guidelines and em codes. An interval history is defined as a summary of events that took place since the last em encounter in the hospital usually the day before. Is documentation of family history noncontributory to patient condition, illness or injury or. Each note is designed to capture the patients interval history and mental status exam as well as the clinicians diagnosis and recommendations. Interval 2000 product documentation from the manufacturer. Question em progress note interval history medical billing and. The em interactive worksheet bases its calculations on the requirements specified in the em documentation guidelines for evaluation and. Base your subsequent hospital care coding on interval history. If the current procedural terminology cpt manual requires only an interval history for a particular category of patient visit, do i need to. The patients hypertension is stable on current medications. Intervals is fully featured and customizable to match your workflow and business. Interval history refers to the change in the patients history since the last history was taken. Detailed history em coding, em evaluation and management. Medical record documentation is required to record pertinent facts, findings, and.