# E & m/emr/ros



## medicalsec (Aug 21, 2011)

If the patient fills out a complete ROS on his initial visit, but the EMR records reflect a limited review will this be satisfactory for a comprehensive review on their first visit. They are using a free EMR which only uses the SOAP format. It is going to be a real headache for me because it does not support E & M calculation and does not prompt the doctor to help them be compliant. It is more of a freehand system. I had thought that they should type the all  other systems reviewed and negative statement since it would correspond to what the patient filled out so that they could cover all of the basis. I was hoping that they would go with a system that would support compliance. It has nothing that supports codiing by time or review of labs, films, etc.  I suspect I will have to code much lower. They are allowed to pick a code at the end of the contact which is based on nothing.  Any thoughts?

Thanks!


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## btadlock1 (Aug 21, 2011)

medicalsec said:


> If the patient fills out a complete ROS on his initial visit, but the EMR records reflect a limited review will this be satisfactory for a comprehensive review on their first visit. They are using a free EMR which only uses the SOAP format. It is going to be a real headache for me because it does not support E & M calculation and does not prompt the doctor to help them be compliant. It is more of a freehand system. I had thought that they should type the all  other systems reviewed and negative statement since it would correspond to what the patient filled out so that they could cover all of the basis. I was hoping that they would go with a system that would support compliance. It has nothing that supports codiing by time or review of labs, films, etc.  I suspect I will have to code much lower. They are allowed to pick a code at the end of the contact which is based on nothing.  Any thoughts?
> 
> Thanks!



You mean it doesn't prompt them to enter useless information, or write the notes for them? So not every encounter note lists the same symptom responses, in the same order, for every patient, nearly every time? Consider yourself fortunate. As an auditor, I can assure you that the EMR funcions that you're missing, are not as beneficial as they sound. EMR software is often inaccurate in calculations of E/M, because it can't take context clues into consideration, to interpret how the doctor's statements translate into required components of History, Exam, and MDM.  The prompts and MACROS have a tendency to directly contribute to duplicative, if not outright cloned, encounter notes. From a compliance standpoint, it's a nightmare. It seems to have the most dramatic effect on older providers, who have spent the majority of their careers using the SOAP note format. Whereas they previously give substantial information, in a way that makes sense, they begin to write notes that are watered down with useless informetion, and sometimes the information selected from ROS prompts, conflicts with statements given in the HPI. Notes are either generic, and void of any insight into the provider's thought process; or they are long and redundant - at times, making it questionable as to whether or not the documentation accurately reflects the content of the visit.
Be thankful that you don't have that headache. That kind of EMR would not do you any favors.


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## medicalsec (Aug 21, 2011)

Thanks for the reply. I think that my concern is that they will miss the basic elements. Unfortunately, before we created a paper template in the office to help them meet the basic requirements some of the notes often consisted of "return prn" on their followup visits and that was about it. I would just like something that listed the basic categories CC: HPI: ROS: EXAM: LABS/TESTS REVIEWED: ASSESSMENT/PLAN, and prompts that would enable them to code by time if it is appropriate, and an area that enabled them to write down what tests were reviewed, and if they personally looked at the films/discussed the case with other providers, etc. I just want something that will not put them back to the same level as writing on a blank piece of paper. I do know what you are saying because we have seen some systems that give extensive "canned information" and it would seem that it would be so easy just to continually cut and paste, and it would be very easy to forget to edit these areas to what is appropriate, and they could be noting things that they are not really doing for this particular patient. They just really need basic prompts to jar their memory in a busy office to note things that they are actually doing. If categories were listed that met Medicare's auditing requirements, it would really solve many problems. I think that many doctors are not compliant because they don't understand that everything is not a four or a five level. It is hard enough for a coder to try and count all the bullets, or if they use the 95 rules you have so many gray areas. Many doctors just guess at a code in a matter of seconds at the end of the contact. They are not sure if it meets the requirements of a consult, or a follow-up visit, or a new patient, etc., and especially since some plans allow consults and others don't. They certainly don't have time to analyze all of the billing criteria in a matter of seconds. I think this is as big of a  problem as having too much canned information.  So far I see these electronic systems either go overboard with information that they put in their system or the free ones are not compliant enough, and so I guess my original concern remains and that is if what the patient initially fills out which includes (ROS info, PFSH etc.) info will that still count as a full review even if it is not mirrored in the EHR system for that visit. I believe all of the papers that they fill out will be scanned into the chart.

Thanks for the response. I am sure as an auditor you have seen it all! You have excellent comments. I just wish these systems would meet somewhere in the middle with their features.


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## btadlock1 (Aug 22, 2011)

medicalsec said:


> Thanks for the reply. I think that my concern is that they will miss the basic elements. Unfortunately, before we created a paper template in the office to help them meet the basic requirements some of the notes often consisted of "return prn" on their followup visits and that was about it. I would just like something that listed the basic categories CC: HPI: ROS: EXAM: LABS/TESTS REVIEWED: ASSESSMENT/PLAN, and prompts that would enable them to code by time if it is appropriate, and an area that enabled them to write down what tests were reviewed, and if they personally looked at the films/discussed the case with other providers, etc. I just want something that will not put them back to the same level as writing on a blank piece of paper. I do know what you are saying because we have seen some systems that give extensive "canned information" and it would seem that it would be so easy just to continually cut and paste, and it would be very easy to forget to edit these areas to what is appropriate, and they could be noting things that they are not really doing for this particular patient. They just really need basic prompts to jar their memory in a busy office to note things that they are actually doing. If categories were listed that met Medicare's auditing requirements, it would really solve many problems. I think that many doctors are not compliant because they don't understand that everything is not a four or a five level. It is hard enough for a coder to try and count all the bullets, or if they use the 95 rules you have so many gray areas. Many doctors just guess at a code in a matter of seconds at the end of the contact. They are not sure if it meets the requirements of a consult, or a follow-up visit, or a new patient, etc., and especially since some plans allow consults and others don't. They certainly don't have time to analyze all of the billing criteria in a matter of seconds. I think this is as big of a  problem as having too much canned information.  So far I see these electronic systems either go overboard with information that they put in their system or the free ones are not compliant enough, and so I guess my original concern remains and that is if what the patient initially fills out which includes (ROS info, PFSH etc.) info will that still count as a full review even if it is not mirrored in the EHR system for that visit. I believe all of the papers that they fill out will be scanned into the chart.
> 
> Thanks for the response. I am sure as an auditor you have seen it all! You have excellent comments. I just wish these systems would meet somewhere in the middle with their features.



Try giving them these handouts: http://trailblazerhealth.com/Publications/Job Aid/coding pocket reference.pdf

http://www.trailblazerhealth.com/Pu... preventing most common e-m coding errors.pdf

You have a responsibility to try to educate them on proper techniques, but not to hold their hand or do it for them. Ultimately, it's their responsibility to do the things that they need to in order to get paid for their work. I understand the concern, but there's only so much you can do. Hope that helps!


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## medicalsec (Aug 22, 2011)

Thanks for your help. I appreciate the links. You are correct that they are really the responsible parties, and they will have to try and learn the rules because the program requires them to pick the E & M codes and diagnoses codes in order to complete the contact. 

Thanks Again!!!


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