\r\n ![]()
\r\n
\r\n | Chief Complaint Documented | \r\n{{scoring.hpiChiefComplaint}} | \r\n
| History | \r\n{{!worksheet.decisionMaking2021 && !worksheet.decisionMaking2023 ? scoring.historyLevel : null}} | \r\n|
| History of Present Illness | \r\n{{scoring.hpi}} | \r\n{{scoring.hpiSelected}} | \r\n
| Review of Systems | \r\n{{scoring.ros}} | \r\n{{scoring.rosSelected}} | \r\n
| Past, Family, and Social History | \r\n{{scoring.pfsh}} | \r\n{{scoring.pfshSelected}} | \r\n
| Medical Decision Making | \r\n{{scoring.decisionComplexity}} | \r\n|
| Type and Number of Presenting Problems | \r\nScore: {{scoring.typeAndNumberOfPresentingProblems}} | \r\n{{scoring.typeAndNumberOfPresentingProblemsSelected}} | \r\n
| Amount and Complexity of Data | \r\nScore: {{scoring.amtandComplexityOfData}} | \r\n{{scoring.amountAndComplexityOfDataSelected}} | \r\n
| Level of Risk | \r\nScore: {{scoring.levelOfRisk}} | \r\n{{scoring.levelOfRiskSelected}} | \r\n
| Time Based | \r\nTotal Time Spent: {{scoring.timeSpentTotal}} | \r\nTime Spent Counseling: {{scoring.timeSpentCounseling}} | \r\n
| {{finding.codeDesc}}{{ ` - ${finding.reasonDescription}`}} | \r\n
|---|
| \r\n Details\r\n | \r\n\r\n \r\n | \r\n
| \r\n Documentation\r\n | \r\n\r\n \r\n | \r\n
| \r\n Reference\r\n | \r\n\r\n \r\n | \r\n
| \r\n {{ checklist.checkListName }}\r\n | \r\n
|---|
| \r\n {{item.itemName}}\r\n | \r\n\r\n \r\n \r\n \r\n \r\n \r\n | \r\n
| Project ID: | \r\n{{ worksheet.projectId }} | \r\n||
| Hospital: | \r\n{{ worksheet.clientName }} | \r\nReview Date: | \r\n{{ formatDate(worksheet.reviewDate) }} | \r\n
| Auditor: | \r\n{{ worksheet.reviewerName }} | \r\nPatient Account Number: | \r\n{{ worksheet.patAcctNum }} | \r\n
| Patient Age: | \r\n{{ worksheet.patientAge }} | \r\nPatient Sex: | \r\n{{ worksheet.patientSex }} | \r\nPatient DOB: | \r\n{{ formatDate(worksheet.patientDob) }} | \r\n|
| Newborn Weight: | \r\n{{ worksheet.newbornWeight ? `${worksheet.newbornWeight}g` : null }} | \r\nMedical Record Number: | \r\n{{ worksheet.mrNumber }} | \r\nCoder Query: | \r\n{{ worksheet.coderQuery ? 'Yes' : 'No' }} | \r\n|
| Coder Query Missed: | \r\n{{ worksheet.coderQueryMissed ? 'Yes' : 'No' }} | \r\nCoder: | \r\n{{ worksheet.coder }} | \r\nReviewer Query: | \r\n{{ worksheet.reviewerQuery ? 'Yes' : 'No' }} | \r\n|
| Payor: Payor Detail: | \r\n {{ worksheet.payorName }} {{ worksheet.payorDetail }} | \r\n APC Change: | \r\nFinancial Impact: | \r\n{{ worksheet.financialImpact ? 'Yes' : 'No' }} | \r\nDate of Service: | \r\n{{ formatDate(worksheet.dateOfService) }} | \r\n
| Physician: | \r\n{{ worksheet.physician }} | \r\nReason for Change: | \r\n{{ worksheet.reasonForChange }} | \r\n\r\n | \r\n\r\n \r\n | |
| Patient Age: | \r\n{{ worksheet.patientAge }} | \r\nPatient Sex: | \r\n{{ worksheet.patientSex }} | \r\nMedical Record Number: | \r\n{{ worksheet.mrNumber }} | \r\n|
| Coder Query: | \r\n{{ worksheet.coderQuery ? 'Yes' : 'No' }} | \r\nCoder Query Missed: | \r\n{{ worksheet.coderQueryMissed ? 'Yes' : 'No' }} | \r\nCoder: | \r\n{{ worksheet.coder }} | \r\n|
| Reviewer Query: | \r\n{{ worksheet.reviewerQuery ? 'Yes' : 'No' }} | \r\nPayor: Payor Detail: | \r\n {{ worksheet.payorName }} {{ worksheet.payorDetail }} | \r\n APC Change: | \r\nFinancial Impact: | \r\n{{ worksheet.financialImpact ? 'Yes' : 'No' }} | \r\n
| Date of Service: | \r\n{{ formatDate(worksheet.dateOfService) }} | \r\nPhysician: | \r\n{{ worksheet.physician }} | \r\nReason for Change: | \r\n{{ worksheet.reasonForChange }} | \r\n|
| Original Dx Coding | \r\nRecommended Dx Coding | \r\n
| Code | \r\nDescription | \r\nHCC | \r\nCode | \r\nDescription | \r\nHCC | \r\nReason | \r\n
|---|---|---|---|---|---|---|
| {{ codeType }} | \r\n||||||
| \r\n {{ dx.originalDx }}\r\n | \r\n\r\n {{ dx.originalDescription }} ({{ dx.originalGrouperFlags }})\r\n | \r\n\r\n {{ dx.originalHccs }} \r\n {{dx.originalHccsV28}} \r\n | \r\n \r\n {{ dx.recommendedDx }}\r\n | \r\n\r\n {{ getDxRecommendedDescription(dx, worksheet.dxs) }} | \r\n \r\n {{ dx.recommendedHccs }} \r\n {{dx.recommendedHccsV28}} \r\n | \r\n {{ dx.reasonForChange }} | \r\n
| Original Px Coding | \r\nRecommended Px Coding | \r\n
| Code | \r\nDescription | \r\nCode | \r\nDescription | \r\nReason | \r\n
|---|---|---|---|---|
| {{ codeType }} | \r\n||||
| \r\n {{ px.originalPx }}\r\n ({{ formatDate(px.procedureDate) }})\r\n | \r\n\r\n {{ px.originalDescription }} ({{ px.originalGrouperFlags }})\r\n | \r\n{{ px.originalDeleted ? px.originalPx : px.recommendedPx }} | \r\n\r\n {{ px.originalDeleted ? getPxDeletedDescription(px) : px.recommendedDesc }} | \r\n {{ px.reasonForChange }} | \r\n
| Original CPT Coding | \r\nRecommended CPT Coding | \r\n
| Code | \r\nDescription | \r\nCode | \r\nDescription | \r\nReason | \r\n
|---|---|---|---|---|
| {{ codeType }} | \r\n||||
| \r\n {{ cpt.originalCpt }}{{ cpt.originalModifierCalc }}\r\n ({{ formatDate(cpt.procedureDate)\r\n }})\r\n | \r\n\r\n {{ cpt.originalDescription }}\r\n | \r\n\r\n {{ cpt.originalCpt }}{{ cpt.originalModifierCalc }} \r\n \r\n | \r\n\r\n {{ cpt.originalDeleted ? getCptDeletedDescription(cpt) : cpt.recommendedDesc }}\r\n | \r\n\r\n {{cpt.reasonForChangeDescription}}\r\n \r\n {{mrfc.reasonForChange}}\r\n | \r\n
| Findings | \r\n
|---|
| \r\n | \r\n
| Checklists | \r\n
|---|
| \r\n | \r\n
| Coder Responses | \r\n|||||
|---|---|---|---|---|---|
| \r\n No Responses on Worksheet \r\n | \r\n |||||
| \r\n Response Date:\r\n | \r\n\r\n {{ formatDate(worksheet.rebuttal.rebuttalDate) }}\r\n | \r\n\r\n Coder Agrees With Changes:\r\n | \r\n\r\n {{ worksheet.rebuttal.agreeWithCodes ? 'Yes' : 'No' }}\r\n | \r\n\r\n Final Outcome:\r\n | \r\n\r\n {{ worksheet.rebuttal.finalOutcome }}\r\n | \r\n
| \r\n Response Comments: \r\n \r\n {{ comment.user.fullName }} on {{ format(parseISO(comment.createdDate), 'M/d/yyyy hh:mm a') }}\r\n \r\n \r\n | \r\n
| {{ finding.reasonDescription }} | \r\n
|---|
| \r\n Details\r\n | \r\n\r\n \r\n | \r\n
| \r\n Documentation\r\n | \r\n\r\n \r\n | \r\n
| \r\n Reference\r\n | \r\n\r\n \r\n | \r\n
| \r\n {{ checklist.checkListName }}\r\n | \r\n
|---|
| \r\n {{item.itemName}}\r\n | \r\n\r\n \r\n \r\n \r\n \r\n \r\n | \r\n
| Project ID: | \r\n{{ worksheet.projectId }} | \r\n||
| Hospital: | \r\n{{ worksheet.clientName }} | \r\nReview Date: | \r\n{{ formatDate(worksheet.reviewDate) }} | \r\n
| Auditor: | \r\n{{ worksheet.reviewer }} | \r\nPatient Account Number: | \r\n{{ worksheet.patAcctNum }} | \r\n
| Patient Age: | \r\n{{ worksheet.patientAge }} | \r\nPatient Sex: | \r\n{{ worksheet.patientSex }} | \r\nPatient DOB: | \r\n{{ formatDate(worksheet.patientDob) }} | \r\n
| Newborn Weight: | \r\n{{ worksheet.newbornWeight ? `${worksheet.newbornWeight}g` : null }} | \r\nMedical Record Number: | \r\n{{ worksheet.mrNumber }} | \r\nCoder Query: | \r\n{{ worksheet.coderQuery ? 'Yes' : 'No' }} | \r\n
| Coder Query Missed: | \r\n{{ worksheet.coderQueryMissed ? 'Yes' : 'No' }} | \r\nCoder: | \r\n{{ worksheet.coder }} | \r\nCDI Query: | \r\n{{ worksheet.cdiQuery ? 'Yes' : 'No' }} | \r\n
| CDI Query Missed: | \r\n{{ worksheet.cdiQueryMissed ? 'Yes' : 'No' }} | \r\nCDI Staff: | \r\n{{ worksheet.cdiStaff }} | \r\nAuditor Query Affects DRG: | \r\n{{ worksheet.auditQuery ? 'Yes' : 'No' }} | \r\n
| Payor: Payor Detail: | \r\n {{ worksheet.payorName }} {{ worksheet.payorDetail }} | \r\n D/C Available for Coding: | \r\n{{ worksheet.dcSummAvailAtCoding }} | \r\nLength of Stay: | \r\n{{ worksheet.los }} | \r\n
| Discharge Date: | \r\n{{ formatDate(worksheet.dischargeDate) }} | \r\nAdmit Date: | \r\n{{ formatDate(worksheet.admitDate) }} | \r\nUB Available: | \r\n{{ worksheet.noUBAvailable ? 'No' : 'Yes' }} | \r\n
| Physician: | \r\n{{ worksheet.physician }} | \r\nReason for Change: | \r\n{{ worksheet.reasonForChangeDesc }} | \r\n\r\n | \r\n |
| Patient Age: | \r\n{{ worksheet.patientAge }} | \r\nPatient Sex: | \r\n{{ worksheet.patientSex }} | \r\nMedical Record Number: | \r\n{{ worksheet.mrNumber }} | \r\n
| Coder Query: | \r\n{{ worksheet.coderQuery ? 'Yes' : 'No' }} | \r\nCoder Query Missed: | \r\n{{ worksheet.coderQueryMissed ? 'Yes' : 'No' }} | \r\nCoder: | \r\n{{ worksheet.coder }} | \r\n
| CDI Query: | \r\n{{ worksheet.cdiQuery ? 'Yes' : 'No' }} | \r\nCDI Query Missed: | \r\n{{ worksheet.cdiQueryMissed ? 'Yes' : 'No' }} | \r\nCDI Staff: | \r\n{{ worksheet.cdiStaff }} | \r\n
| Auditor Query Affects DRG: | \r\n{{ worksheet.auditQuery ? 'Yes' : 'No' }} | \r\nPayor: Payor Detail: | \r\n {{ worksheet.payorName }} {{ worksheet.payorDetail }} | \r\n D/C Available for Coding: | \r\n{{ worksheet.dcSummAvailAtCoding }} | \r\n
| Length of Stay: | \r\n{{ worksheet.los }} | \r\nDischarge Date: | \r\n{{ formatDate(worksheet.dischargeDate) }} | \r\nAdmit Date: | \r\n{{ formatDate(worksheet.admitDate) }} | \r\n
| UB Available: | \r\n{{ worksheet.noUBAvailable ? 'No' : 'Yes' }} | \r\nPhysician: | \r\n{{ worksheet.physician }} | \r\nReason for Change: | \r\n{{ worksheet.reasonForChangeDesc }} | \r\n
| Original {{ worksheet.ipReviewType ? worksheet.ipReviewType : 'DRG' }}: | \r\n{{ worksheet.orDRG }} | \r\nRecommended {{ worksheet.ipReviewType ? worksheet.ipReviewType : 'DRG' }}: | \r\n{{ worksheet.recDRG }} | \r\n
| Original {{ worksheet.ipReviewType ? worksheet.ipReviewType : 'DRG' }} Weight: | \r\n{{ worksheet.orWt }} | \r\nRecommended {{ worksheet.ipReviewType ? worksheet.ipReviewType : 'DRG' }} Weight: | \r\n{{ worksheet.recWt }} | \r\n
| Original SOI: | \r\n{{ worksheet.originalSOI }} | \r\nRecommended SOI: | \r\n{{ worksheet.recommendedSOI }} | \r\n
| Original ROM: | \r\n{{ worksheet.originalROM }} | \r\nRecommended ROM: | \r\n{{ worksheet.recommendedROM }} | \r\n
| Original Patient Status: | \r\n{{ worksheet.orPatStat }} | \r\nRecommended Patient Status: | \r\n{{ worksheet.recPatstat }} | \r\n
| Original Point of Origin: | \r\n{{ worksheet.originalPOO }} | \r\nRecommended Point of Origin: | \r\n{{ worksheet.recommendedPOO }} | \r\n
| Original Patient Safety Indicators: | \r\n\r\n x.reviewLevel === 0)\" :key=\"psi.identifier\">\r\n {{ psi.shortDescription }}\r\n \r\n | \r\n Recommended Patient Safety Indicators: | \r\n\r\n x.reviewLevel === 1)\" :key=\"psi.identifier\">\r\n {{ psi.shortDescription }}\r\n \r\n | \r\n
| \r\n The above Patient Safety Indicator (PSI) information represents potential triggers. Actual PSIs are not able to be calculated\r\n based on limited data. For more information, see ARHQ.gov PSI\r\n Technical Specifications. \r\n | \r\n|||
| Original Quality Measures: | \r\n\r\n x.reviewLevel === 0)\" :key=\"qm.identifier\">\r\n {{ qm.identifier }}\r\n \r\n | \r\n Recommended Quality Measures: | \r\n\r\n x.reviewLevel === 1)\" :key=\"qm.identifier\">\r\n {{ qm.identifier }}\r\n \r\n | \r\n
| \r\n The above CMS Mortality and Readmission Quality Measure information represents potential triggers. Actual readmission and\r\n mortality measures are not able to be calculated based on limited data. For more information, see CMS.gov QualityNet | \r\n
| Grouper Flags Legend | \r\n
| \r\n | \r\n
| Original Dx Coding | \r\nRecommended Dx Coding | \r\n
| Code | \r\nPOA | \r\nDescription | \r\nHCC | \r\nCode | \r\nPOA | \r\nDescription | \r\nHCC | \r\nReason | \r\n
|---|---|---|---|---|---|---|---|---|
| \r\n {{ dx.originalDx }}\r\n | \r\n{{ dx.originalPOA }} | \r\n\r\n {{ dx.origDesc }} ({{ dx.originalGrouperFlags }})\r\n | \r\n\r\n {{ dx.originalHccs }} \r\n {{dx.originalHccsV28}} \r\n | \r\n \r\n {{ dx.recommendedDx }}\r\n | \r\n{{ dx.recommendedPOA }} | \r\n\r\n {{ getDxRecommendedDescription(dx, worksheet.dxs) }} | \r\n \r\n {{ dx.recommendedHccs }} \r\n {{dx.recommendedHccsV28}} \r\n | \r\n {{ dx.reasonForChange }} | \r\n
| Original Px Coding | \r\nRecommended Px Coding | \r\n
| Code | \r\nDescription | \r\nCode | \r\nDescription | \r\nReason | \r\n
|---|---|---|---|---|
| \r\n {{ px.originalPx }}\r\n ({{ formatDate(px.procedureDate) }})\r\n | \r\n\r\n {{ px.originalDescription }} ({{ px.originalGrouperFlags }})\r\n | \r\n{{ px.originalDeleted ? px.originalPx : px.recommendedPx }} | \r\n\r\n {{ px.originalDeleted ? getPxDeletedDescription(px) : px.recommendedDesc }} | \r\n {{ px.reasonForChange }} | \r\n
| Findings | \r\n
|---|
| \r\n | \r\n
| Checklists | \r\n
|---|
| \r\n | \r\n
| Coder Responses | \r\n|||||
|---|---|---|---|---|---|
| \r\n No Responses on Worksheet \r\n | \r\n |||||
| \r\n Response Date:\r\n | \r\n\r\n {{ formatDate(worksheet.rebuttal.rebuttalDate) }}\r\n | \r\n\r\n Coder Agrees With Changes:\r\n | \r\n\r\n {{ worksheet.rebuttal.agreeWithCodes ? 'Yes' : 'No' }}\r\n | \r\n\r\n Final Outcome:\r\n | \r\n\r\n {{ worksheet.rebuttal.finalOutcome }}\r\n | \r\n
| \r\n Response Comments: \r\n \r\n {{ comment.user.fullName }} on {{ format(parseISO(comment.createdDate), 'M/d/yyyy hh:mm a') }}\r\n \r\n \r\n | \r\n
| \r\n {{ finding.codeDesc }}{{ ` - ${finding.reasonDescription}` }}\r\n | \r\n
|---|
| \r\n Details\r\n | \r\n\r\n \r\n | \r\n
| \r\n Documentation\r\n | \r\n\r\n \r\n | \r\n
| \r\n Reference\r\n | \r\n\r\n \r\n | \r\n
| \r\n {{ codeType }}{{ ` - ${checklist.checkListName}` }}\r\n | \r\n
|---|
| \r\n {{item.itemName}}\r\n | \r\n\r\n \r\n \r\n \r\n \r\n \r\n | \r\n
| Project ID: | \r\n{{ worksheet.projectId }} | \r\n||
| Facility: | \r\n{{ worksheet.clientName }} | \r\nReview Date: | \r\n{{ formatDate(worksheet.reviewDate) }} | \r\n
| Auditor: | \r\n{{ worksheet.reviewerName }} | \r\nPatient Account Number: | \r\n{{ worksheet.patientNumber }} | \r\n
| Place of Service | \r\n{{ worksheet.placeOfService }} | \r\nEM Guidelines | \r\n{{ worksheet.emGuidelines }} | \r\nMedical Record Number: | \r\n{{ worksheet.mrnumber }} | \r\n
| Payor: Payor Detail: | \r\n {{ worksheet.payorName }} {{ worksheet.payorDetail }} | \r\n Date of Service: | \r\n{{ formatDate(worksheet.dateOfService) }} | \r\nCoder: | \r\n{{ worksheet.coder }} | \r\n
| Patient Sex: | \r\n{{ worksheet.patientSex }} | \r\nProvider: | \r\n{{ worksheet.physicianName }} | \r\nReason for Change: | \r\n{{ worksheet.reasonForChange }} | \r\n
| Patient DOB: | \r\n{{ formatDate(worksheet.patientDob) }} | \r\n\r\n | \r\n | \r\n | \r\n |
| Newborn Weight: | \r\n{{ worksheet.newbornWeight ? `${worksheet.newbornWeight}g` : null }} | \r\n\r\n | \r\n | \r\n | \r\n |
| Original Dx Coding | \r\nRecommended Dx Coding | \r\n
| Code | \r\nDescription | \r\nHCC | \r\nCode | \r\nDescription | \r\nHCC | \r\nReason | \r\n
|---|---|---|---|---|---|---|
| \r\n {{ codeType }} \r\n | \r\n ||||||
| \r\n {{ dx.originalDx }}\r\n | \r\n\r\n {{ dx.originalDescription }} ({{ dx.originalGrouperFlags }})\r\n | \r\n\r\n {{ dx.originalHccs }} \r\n {{dx.originalHccsV28}} \r\n | \r\n \r\n {{ dx.recommendedDx }}\r\n | \r\n\r\n {{ getDxRecommendedDescription(dx, worksheet.dxs) }} | \r\n \r\n {{ dx.recommendedHccs }} \r\n {{dx.recommendedHccsV28}} \r\n | \r\n {{ dx.reasonForChange }} | \r\n
| Original CPT Coding | \r\nRecommended CPT Coding | \r\n
| Code | \r\nDescription | \r\nCode | \r\nDescription | \r\nReason | \r\n
|---|---|---|---|---|
| \r\n {{ codeType }} \r\n | \r\n ||||
| \r\n {{ px.originalCPT }}{{ px.originalModifierCalc }}\r\n ({{ formatDate(px.procedureDate) }})\r\n | \r\n\r\n {{ px.origDesc }} ({{ px.originalGrouperFlags }})\r\n | \r\n\r\n\r\n {{ px.originalCPT }}{{ px.originalModifierCalc }} \r\n \r\n \r\n \r\n | \r\n\r\n\r\n {{ px.originalDeleted ? getCptDeletedDescription(px) : px.recDesc }}\r\n | \r\n\r\n {{px.reasonForChangeDescription}}\r\n \r\n {{mrfc.reasonForChange}}\r\n | \r\n
| E&M Scoring | \r\n
| \r\n | \r\n
| E&M Scoring Not Specified | \r\n
| Findings | \r\n
|---|
| \r\n | \r\n
| Checklists | \r\n
|---|
| \r\n | \r\n
| Coding Recommendations | \r\n
|---|
| Action Taken | \r\n
|---|
| \r\n \r\n | \r\n
| Location of Supporting Doc | \r\n
|---|
| \r\n \r\n | \r\n
| Coding Reference | \r\n
|---|
| \r\n \r\n | \r\n
| Coder/Provider Responses | \r\n|||||
|---|---|---|---|---|---|
| \r\n No Responses on Worksheet \r\n | \r\n |||||
| \r\n Response Date:\r\n | \r\n\r\n {{ formatDate(worksheet.rebuttal.rebuttalDate) }}\r\n | \r\n\r\n Coder/Provider Agrees With Changes:\r\n | \r\n\r\n {{ worksheet.rebuttal.agreeWithCodes ? 'Yes' : 'No' }}\r\n | \r\n\r\n Final Outcome:\r\n | \r\n\r\n {{ worksheet.rebuttal.finalOutcome }}\r\n | \r\n
| \r\n Response Comments: \r\n \r\n {{ comment.user.fullName }} on {{ format(parseISO(comment.createdDate), 'M/d/yyyy hh:mm a') }}\r\n \r\n \r\n | \r\n
| Medical Decision Making ({{worksheet.decisionMaking2021 ? '2021' : worksheet.decisionMaking2023 ? '2023' : ''}} EM Guidelines) | \r\n{{scoring.decisionComplexity2021}} | \r\n|
| Type and Number of Presenting Problems | \r\nScore: {{scoring.presentingProblemScore2021}} | \r\n{{scoring.presentingProblem2021}} | \r\n
| Management Options | \r\nScore: {{scoring.managementOptionsScore2021}} | \r\n{{scoring.managementOptions2021}} | \r\n
| Amount and Complexity of Data | \r\nScore: {{scoring.documentationComplexityScore2021}} | \r\n{{scoring.documentationComplexity2021}} | \r\n
| Time Based | \r\nTotal Time Spent: | \r\n{{scoring.timeSpentTotal}} | \r\n
| Physical Examination | \r\n{{!worksheet.decisionMaking2021 && !worksheet.decisionMaking2023 ? scoring.examDetailType : null}} | \r\n{{!worksheet.decisionMaking2021 && !worksheet.decisionMaking2023 ? scoring.examDetailScore : null}} | \r\n
| Selected Elements | \r\n{{ scoring.examSelected }} | \r\n