Mar 30th, 2017
Since electronic medical records (EMR) have become prevalent, there has been concern whether documentation in the patient record accurately reflects medical necessity and the services provided. When I started working in the healthcare setting, we always told providers, “Not documented, not done.” Now, when I review a chart note, the question I have to ask ...
In Audit
Sep 15th, 2015
by John Verhovshek, MA, CPC Electronic medical records have simplified documentation and record tracking. In some cases, the electronic record allows the physician to bring forward, or to “cut-and paste,” previous patient information. Although this may save time, progress notes are critical to support medical necessity. For example, if an inpatient’s improvement and/or regression is not ...
In Audit
Jul 1st, 2014
CMS allows providers to use documentation templates, but the resulting encounter note must be specific to the patient, date of service, and service(s) rendered. If you use (or plan to use) documentation templates in your practice, consider these basic compliance guidelines, as provided by WPS Medicare: Either the ancillary staff or the patient may complete ...
In Billing
Oct 1st, 2013
Use these five tips to get more out of EHR and PMS demos. You’ve probably noticed that most electronic health record (EHR) and practice management system (PMS) vendors don’t seem to know anything about your specialty or your practice when they give you a demo. Typical examples include: a sales rep showing an orthopedic group ...
Jul 1st, 2013
Documentation tells a story; make sure the main character is the patient, not the physician. By Leonta Julien-Williams, CPC, RHIT, CCS The electronic health record (EHR) has made it easier for patients to access and monitor their health information. I’m sure you’re aware of the type of information found in a patient’s EHR—from basic demographics ...