Part B Insider (Multispecialty) Coding Alert

Published on Mon May 10, 2004 PDF

It depends on whether your doctor is undercoding

Documentation is the bane of your existence, so the idea of replacing scribbles and transcription services with an automated system sounds tempting.
 
Fans say an electronic medical record can really streamline your documentation. And that improved documentation will improve your evaluation and management coding and boost your reimbursement levels. Some practices reap tens of thousands of dollars from improved E/M levels, according to boosters.

Can you reap these rewards from an EMR? Yes, if your doctor is providing services but not documenting them fully, say experts. Often, doctors will underdocument even when they're providing services that justify a higher E/M level, says Barbara Cobuzzi, president of Cash Flow Solutions in Lakewood, NJ. "They don't have the time to document properly."

Of course, some physicians already provide enough documentation to justify billing 99214 or bill 99215 , but they only bill 99212 or 99213 because they're "petrified of audits," notes Cobuzzi. Doctors are "shooting themselves in the foot" by underbilling.

"The sole purpose is to improve the accuracy of documentation, and as a result of that, physicians may have sufficient documentation and medical necessity to improve a level of  coding," says consultant John McDaniels with Physician Management Group in New Orleans.

McDaniels saw a practice recently that was spending $30,000 a year on transcription. "Let's assume the doctor is undercoding $20,000, that's $50,000. It doesn't take too long for the practice to return its investment," says McDaniels.

"Depending on how it's designed, it will allow me to put in either prompts or reminders or templates or forms that I fill out or checklists that I deploy, so I am more likely to record the things that I am doing anyway, that I forget to write down," says consultant Robert Burleigh with Brandywine Healthcare Services in Malvern, PA. This "provides a good opportunity to create a better record."
 
There are quite a few advantages in terms of the ease of reading it, archiving it, and retrieving it," says Burleigh.