Email not displaying correctly? View it in your browser. Issue #17 — November 23, 2011
AAPC BillingInsider e-Newsletter

F R O M   T H E   F I E L D

Going Paperless Means More than EMR Adoption

Implementing a new electronic medical record (EMR) system is one way to lessen the environmental impact of your office while also cutting costs. Medical records reduced to byte-sized information are obviously less costly and easier to store than paper records. Here are some other tips to help the environment and your bottom line:

  • Install motion sensitive light switches in examination rooms if the practice doesn't already have them. Although a room might be empty only rarely, the additional drain of electricity costs money.
  • As long as you're upgrading your system, purchase equipment meeting the federal government's Energy Star initiative. Improve efficiency by turning off your monitors at night and putting your computers in sleep mode or shutting them off altogether.
  • Rearrange your office. Your practice is set up for a paper world, so look at each space and determine how it can best be used. For example, as the file room is emptied, what revenue-generating purpose can it serve? Do you really need all the office space you have?

Change is difficult but changing the process a little at a time helps your entire staff to "buy in." Make sure each time a familiar process – photocopying, faxing, etc.goes away, the benefits of the new electronic approach are realized.

G O O D   T I P S

Patients of a New Physician – Established or New?
By Brandi Tadlock, CPC, CPC-P, CPMA

As physicians leave solo practices and other groups to join your group, they bring their patients with them. Are these patients new or established?

If it's a single-specialty practice and the physician has seen the patient within the last three years – even if he or she has a different tax ID number than the clinicthe patient is billed using the established evaluation and management (E/M) codes (99211-99215).

Why? According to the American Academy of Family Practice (AAFP), although the physician is new to the group, he or she has been providing professional services to the patient within the last three years. When the patient transferred medical records to the new office is irrelevant, the AAFP says. All that matters is when the provider last saw the patient.

AAFP says a patient who does not transfer his or her care to the new group, and who is seen by another physician in the original group practice, is also established if a physician of the same specialty saw the patient within the last three years.

If the patient follows her doctor to the new group, but chooses to see a physician of a different specialty or sub-specialty within the new group, the patient is "new" as long as that physician hasn't seen the patient within the previous three years. The patient is seeing someone new in a different specialty, rather than a provider within the same specialty who would correctly report the patient as established.

F E A T U R E D   S T O R Y

EMR Transition Is a Great Time to Refresh E/M Documentation Guidelines
By Brandi Tadlock, CPC, CPC-P, CPMA

If your provider is transitioning to an electronic medical record (EMR), take the opportunity to give him a "refresher" course on Evaluation & Management Documentation Guidelines. Many providers are actively involved with the purchase of their EMR systems, and undergo training on how to input information; however, that training often fails to account for the drastic change in documentation style that sometimes accompanies the new technology.

Some EMR features, such as Review of Systems and Exam prompts or MACROS, promise convenience and accurate E/M code selection. When properly used, these features can enhance the provider's documentation by incorporating details that might have otherwise been overlooked. But for providers, all of the new prompted information can create confusion, leaving them second-guessing their understanding of how much documentation is really necessary to support the services they intend to bill. Consequently, they might overuse prompts, leading to notes that contain irrelevant, redundant, and/or conflicting information.

A simple review of the CMS guidelines can help your provider gauge the documentation he or she will need for each encounter. Emphasizing the importance of quality over quantity with regard to documentation requirements will make the transition to an EMR less overwhelming and allow your provider to make efficient use of the time spent recording each encounter, while facilitating truly accurate E/M code selection.

In This Issue
Going Paperless
New/Established Patients
E/M Documentation

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