Part B Insider (Multispecialty) Coding Alert

Perfecting Your Technical Composition

Published on Mon Apr 25, 2016

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How to utilize dictation software to revolutionize your practice

If your E/M codes are lacking, your documentation may be to blame, Bee says. Rushed scribbling rarely translates well to coders and insurers while poorly written notes can come back to haunt you if there’s an audit. Some practitioners are adept at typing quickly on their laptops and tablets during an examination, but the majority miss things because they are concentrating on their notes instead of focusing on their patients.

This is where a speech recognition program like Nuance’s Dragon Medical--Small Practice Edition comes in handy, replacing medical misinformation with enhanced care and increased revenue. In addition to its easy integration with most major EHRs, Dragon software is easy to use, so you can dictate as you administer care.

Audit defense: Bee explains, “I actually dictate in front of the patient. By the time the visit is done, the notes are done...I had an insurance company call me and say ‘well you saw this patient for an hour and a half—how do you remember all that at the end of the visit when you dictate?’ and I said, ‘I don’t—I dictate in front of them.’”

Bee maintains that this type of innovative record keeping is extremely helpful for smaller practices and independent practitioners. Not only is it portable, mobile- and cloud-friendly, HIPAA-secure, and clinically-imbibed, the software is affordable, adding income to your bottom line.

In addition, dictation backs up E/M codes based on time. If you are recording your visit and it’s an hour long, don’t you want to be paid for that hour? Your detailed notes are a fail-safe way to get you the money you deserve for your services.

Being able to provide your coders with readable notes saves your practice money, but also gives you peace-of-mind if insurers come to audit.