Pam Warren
True Blue
We've recently implemented the EMR component of our billing software with mixed results. Although the templates for HPI, ROS PFSH and Exam are wonderful, there are a couple of issues that are causing coder heartburn.
The issue of billing a preventative visit with a sick visit at the same time has always been a sticky one, with our most recent, prior-EMR policy was that the provider must dictate two separate notes...one with the exam components(or a separate handwritten exam form) and the other for the sick visit in standard SOAP format. This worked pretty well, and helped support the whole "separately identifiable/additional work" thing that CPT outlines, but our new EMR product cannot clearly separate this data in a way that could be considered separately identifiable. Additional dictation is not an option, nor are we able to attach a preventative visit template onto the sick visit template. Basically, we view one SOAP note, which lists one CC (preventative), a list of chronic problems, occasionally an HPI, med list, PFSH, an examination, Assessment/Plan, (V70.0, and the same chronics that were listed previously, along with the update on meds, labs (these are sometimes linked to a chronic Dx), and occasionally a referral, but neither the meds or the referral show documentation of what condition they are related to. Occasionally the HPI and ROS don't even relate to each other...for example, HPI details foot pain, and the musculoskeletal ROS states, "no joint pain or swelling, no weakness, normal gait". That 's the "Normal" button on the ROS. Yikes! My solution was to create a separate EMR encounter, but other than the coders, I have very few supporters of this idea.
I will admit that provider training is an issue, as is computer saavy. Still, our documentation guidelines have not changed, and in the above instance, I certainly cannot pull out either a separately identifiable visit, nor can I support additional work that would not normally have been done during a CPE. Any one else living this nightmare?
Pam Brooks CPC
WDH, Dover, NH
The issue of billing a preventative visit with a sick visit at the same time has always been a sticky one, with our most recent, prior-EMR policy was that the provider must dictate two separate notes...one with the exam components(or a separate handwritten exam form) and the other for the sick visit in standard SOAP format. This worked pretty well, and helped support the whole "separately identifiable/additional work" thing that CPT outlines, but our new EMR product cannot clearly separate this data in a way that could be considered separately identifiable. Additional dictation is not an option, nor are we able to attach a preventative visit template onto the sick visit template. Basically, we view one SOAP note, which lists one CC (preventative), a list of chronic problems, occasionally an HPI, med list, PFSH, an examination, Assessment/Plan, (V70.0, and the same chronics that were listed previously, along with the update on meds, labs (these are sometimes linked to a chronic Dx), and occasionally a referral, but neither the meds or the referral show documentation of what condition they are related to. Occasionally the HPI and ROS don't even relate to each other...for example, HPI details foot pain, and the musculoskeletal ROS states, "no joint pain or swelling, no weakness, normal gait". That 's the "Normal" button on the ROS. Yikes! My solution was to create a separate EMR encounter, but other than the coders, I have very few supporters of this idea.
I will admit that provider training is an issue, as is computer saavy. Still, our documentation guidelines have not changed, and in the above instance, I certainly cannot pull out either a separately identifiable visit, nor can I support additional work that would not normally have been done during a CPE. Any one else living this nightmare?
Pam Brooks CPC
WDH, Dover, NH