Optometry Coding & Billing Alert

Put legible records at your fingertips and watch compliance glitches disappear 

If you-re not using electronic health records yet, now's the time to consider a switch to a paperless office.
 
Despite the cost of installing an electronic health records system in an office, EHR (also known as -e-records-) has made life easier on many healthcare professionals. The federal government is even trying to encourage greater e-records use, offering free EHR software to smaller offices.
 
Expect the transition period from paper to digital records to be long and awkward, but experts say EHR can help streamline billing processes and improve the office's return on its claims in the long run. EHR also speeds up patient care and reduces expenses for paying transcribers and compliance risks due to illegible documentation.

Compliance Gets Easier

Billers who use an EHR system often find that the office is much more efficient because all e-records are clear, neat and stored in one place.
 
-All e-records are completely legible and more thorough than would typically be the case with handwritten notes,- says Jim Collins, CPC, CEO of an organization of practices in Matthews, N.C.
 
When an office uses EHR, billers don't have to spend as much time deciphering an optometrist's penmanship. Not only will this make your billing procedure faster and more efficient, but EHR will make reading patient records less frustrating.
 
Advantage: When you enter information into an EHR, it is stored there until you delete it; a handwritten note could get lost or damaged, while those risks are practically nil with e-records.

EHR Info More Readily Accessible

Another advantage is faster access to records, because they are stored electronically rather than in physical files. With EHR, the biller, as well as the optometrist, does not have to be in a specific place to view records; all that the billing and optometry staff need is a computer to check a patient's record.
 
With EHR, optometrists -have their entire patient base at their fingertips and have the ability to share the same record among multiple practice locations,- as well as in the facility setting and at the provider's residence, Collins says.
 
Protect yourself: Some optometric records management software will notify you if you haven't checked off enough descriptions or exam points to bill for the procedure code you select, says David Gibson, OD, FAAO, a practicing optometrist in Lubbock, Texas.
 
And, when an office has EHR, -critical information can also be culled from the record database to facilitate important patient-care functions, identifying patients with certain conditions, locating patients impacted by a recall, generating a list of potential clinical-trial candidates, etc.,- Collins says.

Be Aware of the Risks

No office should consider EHR without addressing its inherent risks. -The office should work with its software vendor to learn about the EHR's security features and then develop written policies and procedures to administer them,- says Tom Stevens, a consultant with the Enterprise Systems Group in Macon, Ga. The most common EHR systems fail to provide a good audit trail that would allow you to figure out who changed what.
 
Problems: Many EHR systems allow -canned- documentation that a provider cuts and pastes from a previous visit or a template, according to a study of about 30 products by consultants Patti Trites and Reed Geltzer with Advocates for Documentation Integrity and Compliance in Augusta, Mich. And with many systems, you can't even find a record showing that the provider used -canned- documentation at all.
 
You should have policies and procedures that spell out how your practice deals with information, and have everyone concerned sign off on them, says consultant Norman Brooks with Lee-Brooks Consulting in Chicago.
 
Make sure your system has an audit trail and that you can access it without being a programming whiz, Trites says. Make sure your system doesn't delete audit information at the end of each day. And ask whether your system will meet Health Insurance Portability and Accountability Act standards, she says.
 
Also, ensure that employees don't use each other's computers and accounts so you can tell which employees made which changes, Brooks says.