Neurosurgery Coding Alert

Weigh the pros and cons to pick up and implement the best system.

Ever wondered what you do when electronic medical records (EMRs) replace the paper medical records. Documentation may perhaps get easier. You may advance to improved efficiency, compliance, and coding. But you could be unwittingly introducing new challenges that could really complicate things. Visit the pros and cons of EMRs before you select one for your practice.

Get the Bang out of Big-Buck Systems

With hundreds of products available, it’s important to find the best match for your needs, experts say. Thus, the first step is figuring out which features you want from an EMR system.

Your practice should do thorough needs assessment that defines exactly what you want the EMR system to accomplish. Just like any technology, EMRs come with all sorts of bells and whistles that may or may not be appropriate for your practice. You need to decide what your practice does – and doesn’t – need.

For specialty practices, such as a neurosurgery office, the physician will want to make sure that the system follows his routine for exam and treatment and that his specialty codes are easy to find and assign. For example, a neurosurgery practice will like want to have the 1997 E/M Guidelines’ neurology specialty exam criteria, along with the 1995 guidelines and the 1997 general multisystem criteria built into its EMR system.

Look for a system that’s intuitive. EMR requires staff to learn new routines while they are learning new software so finding a system that will make the transition the least painful will encourage staff buy-in.

Ask about interfaces. Depending on the EMR, you could have built-in billing plus physician order entry and lab and pharmacy interface. Figure out what’s essential for your practice and what can be added on later. It’s also important to choose an EMR system that will be compatible with other systems your practice might use.

Check Out EMRs in Action

Once you know which features matter most to your office, you can start looking at products. Start by contacting vendors or visiting a trade show at a conference you’re attending. But don’t take a sales rep’s word on how good his or her product is: Ask for references. If a vendor has a good product, then it should have business office managers who are willing to talk to you for 10-20 minutes on the phone.

You should be able to visit practices that are using the system. And if you can, try to get a visit that isn’t vendor-controlled. That way, it will be easier to ask questions about the office’s practical experience with the system. Plus, it’s always good to make sure you aren’t the first customer.

Everyone in your practice who will be using the system should spend as much time as possible watching other people use it and learning what they do and do not need.

Highlight the Pros

EMRs can make your billing life easier. Experts say that in the long run, EMRs can help you become more efficient and more accurate, and may even help improve your return on claims. EMR systems can also speed up patient care and reduce expenses for paying transcribers and reduce compliance risks due to illegible documentation.

Improved coding: Practices often find they can use higher codes when they use an EMR because they have clearer documentation of what they did during a patient visit. Physicians are still responsible for coding according to E/M guidelines, but industry experts find EMR systems improve the documentation that supports codes and, therefore, lead to more accurate coding.

Don’t expect EMRs to change the way you code, however. Your physician must still know and understand coding and E/M guidelines, and those guidelines are the same whether your patient charts are electronic or paper. Practices note an increase in higher-level E/M codes with EMR systems because their documentation is more complete. Thus, with better documentation, when higher levels of care are provided, the higher E/M codes are substantiated.

Improved office efficiency: By having patient information readily accessible to all pertinent staff members, your office will save time and effort, ultimately running more efficiently. EMRs will give you the ability to access information when necessary.

Improve staff productivity: With increased efficiency comes increased productivity. EMRs allow entry of patient orders at the point of care, linking results of patient records, and eliminating most paper. Plus, if you use a paper superbill, you have to do a lot of typing. That takes time and necessarily includes mis-keying a percentage of claims. With an EMR, there’s no need to key in codes because the clinician has done that at the point of care.

Improved patient satisfaction: Quicker access to patient information, ease with scheduling, and billing will naturally lead to increases in patient satisfaction.

Faster processing: Presumably, with an EMR claims get posted and sent to the insurance company faster, speeding up payments and reducing the time claims spend in A/R.

Improved documentation and lower rates of error: EMR systems solve issues of illegible handwriting, reduce data entry errors, and help eliminate missing/required patient information. Plus, when you do encounter a coding error, you can easily fix it and submit affected claims.

Improved and easier HIPAA compliance: You should select an EMR system that helps, rather than hinders, your HIPAA compliance. With good security and password use, electronic methods can make HIPAA compliance easier than securing paper records. Look for systems that protect patient information and allow you to secure the information you record in the system.

Expanded backup options: Electronic systems allow you to have automated backups of your information. The system could include on-site or off-site storage of the information. This allows you to develop a plan as to what you can do should your office become unavailable, such as in a natural disaster or fire at your office.

Improved quality of care: With complete and immediate access to patient records, your providers may be able to provide better, faster, more personalized care.

Reduced expenses: By eliminating your need for most transcription activity, cutting your need for file clerks, and dramatically reducing your need for paper storage facilities, your office will save money in the long run.

Fewer missed charges: With the ability to create specific documentation templates for physicians as well as the elimination of lost superbills, you’ll likely see a reduction in services that just never get billed.

Don’t Forget to Weight the Cons

Before selecting a system, be sure you review the downsides of EMRs as well.

Copy and paste errors: Many EMR systems allow “canned” documentation that a provider cuts and pastes from a previous visit or a template.

Tracking challenges: Another problem is that most EMR systems fail to provide a good audit trail. Many systems don’t show who made a change to a record or when they made it. On paper, it’s easy to tell if someone scribbled on a chart or used liquid paper to erase something.

Best bet: Have someone who’s familiar with the principles of health information management (HIM) help you select a system and ensure the following:

1. Make sure that your system has an audit trail and that you can access it without being a programming whiz.

2. Make sure your system doesn’t delete audit information at the end of each day.

3. Ask whether your system will meet the standards of the Health Insurance Portability and Accountability Act (HIPAA).