Purchase STAT E&M Coder™
				Counts your documentation elements during dictation Avoids using nonspecific terms like "Problem Focused" or "Straightforward" Includes templates for the 10 HCFA organ-specific exams and 17 E&M visit types Logical Medical Decisionmaking calculation Saves records for audit purposes if desired
				Download Demo Runs on any Palm OS type PDA (see above list). Fully functional free trial prior to purchase Register for continued use for only $75 (2 year license)

Using Handheld Technology to Make Evaluation & Management Coding Work For Clinicians

    Is Evaluation & Management (E&M) coding a problem for your practice?  Of course, it is.  Private and government health plans are finding that office visits, consultations, inpatient visits etc. are a lucrative area for auditing and downcoding services retroactively.  Some clinicians are chronically vulnerable to retrospective coding audits due to insufficient documentation.  Others routinely undercode their services, accepting significantly lower reimbursement for fear of being penalized in the future.

You really have a terrific E&M product....When we first discovered it (by surfing the net) we tried very hard to prove it wrong before integrating it into any sort of training module or making recommendations to our clients. We are pleased to tell you that it passed all our tests! - Pro Fee Billing Specialist, Inc.

    E&M coding is both a compliance and a revenue problem for most physician practices.  Most clinicians tend to undercode established patient visits and overcode new patient visits (J Am Board Fam Prac. 2001; 14:184-192).  Even determining the extent of the problem can be expensive.  Coding experts often charge $25 - $35 per chart to audit E&M documentation.  This software can be purchased for less than the cost of auditing a few charts.  It will run on a PDA that costs as little as $99 (see compatibility page).

On the administrative side, the STAT E&M Coder software on his Palm has helped [an internist] avoid undercoding, a common mistake of doctors who fear being audited. This simple program has raised his income 20 to 30 percent... - Medical Economics (Spring 2002)

    STAT E&M Coder is a unique handheld tool that efficiently helps the motivated clinician take the guesswork out of the coding and documentation process.  This versatile electronic template has been developed by a practicing physician to automate the complex HCFA 1995 or 1997 coding algorithms at the time of dictation.  It counts the documentation elements, keeps score in real-time, and navigates the complex HCFA documentation rules to show the clinician exactly where they stand in terms of  documenting outpatient, consult, emergency department, and inpatient visits correctly.  Best of all, this software runs on your Palm OS PDA, available to you no matter where you are. 

Read recent journal articles online (AMA News, Family Practice Management, etc.) featuring this software.

       

    STAT E&M Coder works like an interactive E&M checklist carried in your pocket.  There are four main input screens: History; Exam A; Exam B; MDM (Medical Decisionmaking).  Each button represents a documentation element.  As you are dictating your note, click off the items that you are documenting.  There are 17 different visit types to choose from (office visits, consults, inpatient, etc.)  and 11 types of exams to choose from: the general multi-system exam and ten organ-specific exams.  Many clinicians do not realize that the organ-specific exams are available for any clinician to use, not just those in a particular subspecialty.

           

The software "has made me very confident about distinguishing between level 3 and level 4 office visits. The program's status bar clearly shows the elements needed for various levels of care in a way that manuals never effectively do." (ACP-ASIM Observer, Nov. 2002)

    The scoreboard at the top of the screen indicates the level of documentation achieved for the history, exam, and medical decisionmaking sections (i.e. Problem focused, Expanded problem-focused, Detailed, or Comprehensive) . The last box suggests a CPT code (i.e. 99XXX).  If counseling & coordination comprise more than half of an encounter, click the time spent on the last screen and a level will be suggested.

    A unique feature of STAT E&M Coder is the "coding ladder" display.  Selecting the STATUS button at any time graphically displays available coding levels and the documentation levels that you have achieved.  It also displays the applicable Work RVU and Total RVU values for each E&M CPT Code.  A new feature also displays a hint as to what elements are needed to improve the coding level.

    A memo pad record documenting coding levels can be generated for record-keeping & audit purposes.  This memo will synchronize to a PC along with other Palm OS memo files.  Tapping the MENU icon will display text from the HCFA 1997 documentation guidelines.  Each organ system label, when tapped, opens up to display the specific documentation guidelines for that system.

[A CPC billing supervisor] uses STAT E&M Coder on her Handspring personal digital assistant to help her audit the coding of the doctors at her practice.  [She] occasionally audits a chart by hand to verify the precision of her coding program, but so far, she says it has been completely consistent with textbook guidelines.  "I have tested this [program]," she asserts.  "It saves me a lot of time so I can educate the doctors [about their coding]." - Part B News Online

    Since STAT E&M Coder only guides the documentation and coding process for the clinician, it can be used during any dictation process regardless of the setting.  No interface to electronic medical record systems or billing systems are required.  The end result is a precisely documented and accurately coded encounter that is uniquely worded in the clinician's own words avoiding the problematic "boiler-plate" appearance that can raise questions about the veracity of medical documentation.   The use of STAT E&M Coder is completely transparent during a chart audit.

    STAT E&M Coder is compatible with all Palm OS handhelds.  As of July 2001, HCFA development of new E&M guidelines have been scrapped.  No new guidelines are in the works.  The HCFA 1995 and 1997 guidelines currently used in STAT E&M Coder will be in effect for the foreseeable future.  Read this link for more information.

"STAT E&M Coder is an easy-to-use handheld application for enumeration of clinical encounter elements and assignment of service-level CPT codes....Take the drudgery out of documentation, and give STAT E&M Coder a try!" - Digital Assistance / Internal Medicine News, Feb 1 2003

Key Benefits

	Contains all  HCFA organ-specific exams and all services in  which HCFA guidelines are defined
	Ensures accurate coding
	Avoids template/checklist appearance of documentation
	Facilitates more efficient documentation - it tells you what counts  and what does not
	Provides feedback about documentation elements that may be lacking
	Is intuitive and easy to learn
	With experience, is actually needed less and less - coding correctly  becomes second nature
	Completely portable - carried in your pocket on your Palm OS handheld device
	Low implementation costs - pays for itself on the first day of use
	Proprietary, field-tested coding algorithms not found in any other software on any other device

Description	Period	Price
Fully Functional Demo	30 Uses	Free
Single PDA License	2 Years	$75
License Renewal	2 Years	$25
10 or More	2 Years	Contact Us

	Demo this software free of charge.  It's fully functional for dozens of cycles.
	Registration is $75 per user for a two year license.  There are no other fees.

	Rapidly and accurately document all types of  Evaluation & Management services
	Code to meet either HCFA 1995 or HCFA 1997 documentation guidelines
	Learn the type of documentation required for higher levels of service
	Utilize the components of any organ specific exam regardless  of specialty
	Document more completely by prompting relevant history  and exam points
	Ensure appropriate reimbursement while minimizing  compliance risk
	Mitigate the effects of insurer's downcoding techniques by  ensuring adequate documentation

	Runs on any Palm OS handheld device
	Uses only about 180K of Palm memory
	Single file download & install. No other programs or runtime engine are required.
	Only three or four input screens: History, Exam (1 or 2), and MDM
	Extensive text of the HCFA 1997 E&M coding documentation guidelines are included in the software
	Feedback in graphic form regarding what has been documented and, specifically, what has to be done to achieve a given coding/reimbursement level
	Detailed record-keeping is synchronized to a PC for audit purposes using the standard Palm OS memo function (see example)
	Software may be installed and updated via infra-red beaming from one unit to another and conveniently registered via this web page.
	All instructions are found within the software itself.  There is no external manual.

	HCFA 1995
	HCFA 1997 General Multisystem
	Cardiovascular
	Ears, Nose, Mouth and Throat
	Eyes
	Genitourinary (Female)
	Genitourinary (Male)
	Hematologic/Lymphatic/Immunologic
	Musculoskeletal
	Neurological
	Psychiatric
	Respiratory
	Skin

	Office or Other Outpatient Services
	Hospital Observation Services
	Hospital Inpatient Services
	Consultations
	Emergency Department Services
	Nursing Facility Services
	Domiciliary, Rest Home (eg, Boarding Home), or  Custodial Care Services
	Home Services

	Each user must have an understanding of the applicable documentation guidelines as this is simply a reference tool.
	Nothing replaces periodic internal coding audits.
	Coding to a higher level simply because the documentation guidelines appear to support it is improper.
	There are some excellent links listed on this site regarding E&M coding issues.

Integrate E&M coding into EMR.  Software development services available.  Contact Us.