1. R

    EMR "diabetes without complications" documented with codes listed under "with"

    Advice needed. Many EMR systems allow the providers to "pick" their diagnoses from a drop down list. Most providers know that diabetes is coded as E11.9 and will automatically grab this diagnosis, no matter what the complications are (we all know they are not coders and do not recognize the...
  2. KStaten

    Question What is the BEST EMR System you have ever used?

    Hello Everyone! :) Just out of curiosity, what EMR system(s) do you prefer for outpatient coding (especially for orthopedic / neurological practices)? Pros and Cons would be great! :D Thank You in advance! Kim
  3. T

    Timiah Covington Resume

    Clinical System Trainer: Provide training on new functionality, new builds, and new modules of DoD EMR/EHR in the direction of the medical group leadership. Develop site-specific course materials and training plans. Document all users' training and daily contacts with copies to site lead...
  4. C

    Finally getting EHR now which one?

    Our small Orthopedic surgery clinic is finally taking the plunge in 2019! So excited. So now we are trying to find the right software for us. We have 8 Surgeons each with their own sub specialty. We offer clinics in three locations, and operate in three different facilities. Our doctors...
  5. G

    EMR/EHR documentation

    Our providers have started using canned text for PFSH. We are not sure why but are questioning the validity of this text. "Past medical, surgical, and family histories reviewed for relevance to current acute and chronic problems." We clinic coders do not feel this is sufficient documentation...
  6. K

    What constitutes a patients medical record?

    At the clinic where I work when vaccines are given they are recorded online in a state registry but nowhere within our EMR. I have been told that the state registry is a part of the patients medical record and therefore that is sufficient documentation. But since we don't maintain that registry...
  7. M

    EMR/EHR loophole?

    My Physicians wife has come to me asking me to research loopholes of anyone that DOES NOT have to opperate with an Electronic Record, in other words they are wanting to go back to paper charts. Does anyone have a link as to where I can find something showing them in black and white there is no...
  8. H

    EHR for Pain Management Practice

    Hi All, I work at a pain practice and the physician mainly does nerve blocks under ultrasound guidance and trigger point injections. We are looking for an EMR...FINALLY! :D Could you recommend systems for pain in particular? Thanks very much, Heather
  9. T

    Physician needs proof

    One of the physicains I code for does not think she needs to add the diagnosis to the assessment portion of the EMR. She likes to use the special history and put everything in there. She feels that to put the diagnosis in the assessment is doing double documentation and she does not like to do...
  10. K

    What are the rules regarding inactivating patients in your EMR?

    Can anyone direct me to where I can find info regarding whether it is or is not permissible to inactivate a patients chart and how long you have to wait to do this? I know that (in my state at least) if you haven't seen a patient in three years they are no longer considered your patient. But if...
  11. L

    Interim EMR solution

    We are currently an Epic user, EMR and professional billing. We are expanding to another site, which will not be on Epic for another 18 months to 2 years. We'd prefer to not remain on paper at this site. I'm interested in suggestions for an interim solution. Some type of anesthesia record...
  12. S

    Medicare/GI - Colonoscpy with EMR ..different lesion, G6021 deleted..need new code

    Does anyone know the unlisted procedure code for EMR procedures? G6021 is deleted for 2016 and need to know the alternate/crosswalk code. Or is 45390 or 45399 now payable by Medicare? Any thoughts?
  13. A

    Medical Paying G6021 for Colonoscopy with EMR

    Medicare Paying G6021 for Colonoscopy with EMR Has anyone had any luck getting Medicare to pay G6021 for a colonoscopy with EMR? The CPT code is 45390.
  14. H

    Documentation within the EMR

    Good Morning, We are one week into using Athena as our EMR. We are a small 1 physician practice. My physician is having difficulty understanding why a conuslt/soap note is still required if he is "checking" off all the pertinent boxes. I know that we need it, but am looking for some helpful...
  15. D

    AAPC EMR Pilot Program

    Calling all current and future EMR users, Here at the AAPC, we are moving forward with an effort to get more involved with the EMR movement to help prepare our members and the healthcare community as a whole for what lies ahead with EMR implementations and increased usage. Based on this forum...
  16. W

    Experienced CPC seeking remote coding jobs

    Wanda Speh, CPC Advanced Medical BCS, Inc. Brunswick, Georgia 31523 CPC with 15 years of experience is seeking remote medical billing and coding positions part or full time. I am available immediately for ICD-9 and CPT coding/billing for Anesthesia, DME, Pediatrics, Radiology, Pathology and...
  17. N

    Dilema: EMR templates documents things that were not done

    I am facing a ethical dilema here at work. The family physicians use a template for their office visits. The templates are pre-loaded with ROS and exam documentation, and it is up to the physician to edit such. The problem? The physicians do NOT edit. The office visit documentation for an...