I hope you’re sitting down, because there is big news! The proposed physician fee schedule rule was released in mid July and includes a section about E/M (evaluation and management services). CMS is asking for comments about changing the documentation guidelines! The current guidelines were developed in 1995 and 1997, prior to the adoption of electronic health records by most medical practices. Let me start this article by quoting the proposed … [Read more...]
A Rose by Any Other Name | EMR and Compliance
Recently, a physician told me she wasn’t copying from one note and into the current note. She was importing the entire prior note and editing it, since her hospital policy doesn’t allow copying and pasting. It reminded me of Juliet saying about Romeo, “A rose by any other name would smell as sweet.” Electronic Health Records (EHRs) and copy/paste I was reminded of this by an article in JAMA internal medicine published online May 30, 2017. It … [Read more...]
Can I Get Paid if…I Copy and Paste from a Prior Note
Many health records make it easy to copy and paste from a prior note or import the patient's history. From a coding perspective, is that okay? https://player.vimeo.com/video/170232054 Back to list Relevant Search Terms: EHR, electronic medical records, EMR, copy, paste, prior note … [Read more...]
Non Face-to-Face Prolonged Service – 99358
Are you up-to-date on the requirements for non face-to-face prolonged services? This article from Betsy's signature resource Everyday Medical Coding reviews prolonged service codes 99358 & 99359. Does this sound familiar? Before a visit with a new patient, the physician or non-physician practitioner receives old records. A stack of old records. And, these EHR printouts aren’t always organized in any way and frequently include pages and … [Read more...]
Cloning: I Read the News Today, Oh Boy.
Certain medical stories are irresistible to the popular press: ICD-10 external cause codes that are ridiculous (W61.43XD, pecked by a turkey, subsequent encounter) or medical practices using their electronic health records in a way that increases their revenue. A recent headline was eye-catching, as headlines are meant to be, “Report finds more flaws in digitizing patient files.” The New York Times reported on January 8, 2014 that the Office of … [Read more...]
No Chart Left Behind: Deadline to Complete Medical Records
Years ago, I worked with a physician who was chronically behind in dictating his notes. The charts were crammed into boxes by date, lining the walls of his office. Sometimes, they flowed over into the hallway or into the break room. This caused major inconveniences when a patient called for a lab result or returned for a visit. I know you can picture this: the staff hurrying around the office with a list of charts for which they were … [Read more...]
Your HPI: it should be longer than a tweet
The history of the present illness should be longer than a tweet and twice as informative. Any twitter users out there? If so, you know that 140 is the maximum number of characters, including punctuation and spacing. Why bring this up in the context of electronic health records? Because too often, the HPI in EMR notes is shorter than a tweet. And less informative. The history of the present illness describes the reason for the visit and … [Read more...]
Less is More: Don’t let your EMR run away from you
“My medical assistant populates the past medical, family and social history in every note.” Reading hundreds of medical records each month, I’ve come to the conclusion that less is more in physician documentation. I’m singing a different song this year, from the one I and many other documentation specialists sang in previous years, when we implored physicians to add detail to their notes, describe their clinical thinking more fully and in … [Read more...]