Medicare Compliance & Reimbursement

Tip: Focus on your patients, not your notes.

If you repeatedly face downcoded or denied E/M claims, your documentation may be to blame, says Lee Peter Bee, DO, DC MS, FACOI, a solo practitioner with Southern Illinois Medical Specialists in Sesser, Ill. You need strong documentation of exactly what you did and how long you spent with the patient, which hasty scribbling rarely presents. Apart from coders and billers being unable to read illegible writing, you also stand to have your attention diverted from your patients if you are writing or typing notes during the exam.

This is where a speech recognition program like Nuance’s Dragon Medical — Small Practice Edition comes in handy, replacing medical misinformation with enhanced care and increased revenue. In addition to its easy integration with most major EHRs, Dragon software is easy to use, so you can dictate as you administer care.

Audit defense: Bee explains, “I actually dictate in front of the patient. By the time the visit is done, the notes are done ... I had an insurance company call me and say ‘well you saw this patient for an hour and a half — how do you remember all that at the end of the visit when you dictate?’ and I said, ‘I don’t — I dictate in front of them.’”

Bee maintains that this type of innovative record keeping is extremely helpful for smaller practices and independent practitioners. Not only is it portable, mobile- and cloud-friendly, HIPAA-secure, and clinically-imbibed, the software is affordable, adding income to your bottom line.

In addition, dictation backs up E/M codes based on time. If you are recording your visit and it’s an hour long, don’t you want to be paid for that hour? Your detailed notes are a fail-safe way to get the money you deserve for your services.

Being able to provide your coders with clear notes saves your practice money, but also gives you peace-of-mind if insurers come to audit.