Coding & Billing
Electronic Medical Records (EMR)
Some clients erroneously believe that having an EMR or electronic health record (EHR) assures accurate coding; this is rarely the case. While EMRs can perform many front-end edits and checks, a coder’s skill in interpreting the medical documentation is key to proper reimbursement.
Most EMRs use templates for progress notes. While this is a time-saver for the clinician, templates can be dangerous. To begin with, templates are not always accurate. It is not unusual for a coder to see a man diagnosed as pregnant or women with prostate cancer. Templates may also be rife with inaccuracies, where in one section of the note, the clinician reports a finding and in a relevant section reports the condition as normal. Aside from being a potential liability, discrepancies like these can result in inaccurate payment or undue scrutiny from a payor.
Another frequent error with templates occurs when providers check systems that are unrelated to the chief complaint for the visit. This can occur in error, which – again – impacts the provider’s liability. However, if these systems were checked in order to increase the visit level and hence, reimbursement, the behavior may be considered fraudulent and result in overpayment which can then be challenged upon review. Overpayments are embarrassing and costly for the practice in more than just financial terms.
In these cost-conscious times, payors are increasingly scrutinizing medical documentation to assess the medical necessity of the services. Because EMRs often use templates and check-boxes, providers frequently report having assessed more systems than warranted for the chief complaint associated with the visit. The EMR codes the visit level based on the assessment and may assign a higher than appropriate level for the visit, resulting in greater – but incorrect – reimbursement. Upon review by the payor, the claim could trigger an audit, with associated penalties, because, for example, a comprehensive examination is not usually appropriate for a patient presenting with an earache. In today’s healthcare environment, these seemingly simple mistakes could be interpreted as fraud and subject the provider to undue scrutiny.
Hidden Revenue and Other Errors
It’s not unusual for providers to bury minor procedures and services in the visit documentation and forget to bill for them. Some key examples are EKGs and venipuncture. Our coders are adept at identifying forgotten procedures that are not being billed. In addition, some EMR/EHR systems do not regularly update their dictionary of codes. Consequently, providers may not be optimizing their coding despite having thorough documentation.
CCG coders are skilled at educating practitioners on proper documentation and coaching their development. This ensures the provider will be better able to fully reap the EMR system’s billing prowess, enjoy greater profitability and ensure compliance.