Electronic Medical Records

Pam Brooks

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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
 

mrssnail

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We are going live with our first site for outpatient EMR Feb. 08. We are getting our system built by Epic. I am sure we have the same concerns, what with smart text programs and the ability to document more than is really necessary for those "simple" visits.
 

mstenochs

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I am a training coordinator for an EMR / PM system. My suggestion for billing a preventative and sick visit is to create two separate encounters. This way your system will recognize both the sick visit template and the preventative.
The key to getting the most out of your EMR is to ask any and all questions when you are going through training. If you still are unsure you should have a "hotline" number to call for support. especially through the first couple of months when you will run into about a million senarios that you did not think about during training.
 

Dmay

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Sick/Well Encounter

Tammy,
As of 9-1-07 our facility became an FQHC (Federally Qualified Health Center), we are going to look at Nextgen software. Could you share you wow's and woe's of this program.

Thank you,
Dawn May, CPC
 

mstenochs

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Pam
I am not real familiar with the Nextgen system. The only downfall that I can think of is that it is a web based system, that means if your internet goes down or even if their internet goes down, your practice goes down.
The best systems are generally Lynix based. To date they have no known viruses, and they do not "go down". They also have an on site server and are backed up randomly several time a day off site. (This is something that you should find out if Nextgen does).
A couple of the possitives about Nextgen are the customizations that they offer.
I have actually never worked on this system so my suggestion would be to contact the company and find out if they have any clients that would be willing to sit down and talk about their personal experience with the program and the support that they recieve from the company, and what the turnaround time is for upgrade and customizations.
I would also try to find out what type of training support you will have and if they put a timeframe on that support.

Best wishes
 

tekocz04

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re: EMR

Hi Pam, I'm new to coding and just completing an externship---can feel the pain of coding and I don't have the job yet. That is a real problem with the EMR not having the correct components what a coder needs for documentation---nobody ever involves coders when they undertake a new M.I.S. system implementation---come one computer programmers write and code the program for the EMR---they don't understand a coders' job responsibilities fully. Also, the headaches with the electronic billing---I think coding is fading away---some day all the codes will be built into the system and up for acceptance and/or rejection of claims. One wonders if they should pursue the coding field?

Terry
CPC-A


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
 

Pam Brooks

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Thanks, Tammy. Our Medical Information Director took one look at the one EMR note and immediately facilitated a policy to generate two encounters to support the 'separately identifiable' need. Phew!

Terry, I just got back from the NextGen conference, and although the software works great right out of the box, it does require a great deal of template building and customization...both of which require coding expertise and training. I don't think I have to worry about a job for awhile! The trick is to stay up-to-date with coding changes and guidelines. Pam
 

rachlowe

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We are currently in the market to purchase an EMR and I am glad you posted this comment because this will likely be an issue in our practice as well. Please keep me posted if you find resolution...in the meantime I will query the few vendors we are dealing with to see what there suggestions are.

Rachael Milley, CPC
Martin Memorial Medical Group
 

sunchips

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Coding woes

Hi Pam

I read your post and I am glad you got an answer to your problem and you are not alone. I am new to the coding world but I was taught very well. The problem I am having is that I have a wonderful system but the practice doesn't like to let the EMR system "work" for them. Also, when I try to tell them anything, they ignore me. I used to speak up a lot more but now I am kind of going with the flow because the last Biller that tried to let them know of the mistakes being made (especially with incorrect insurance information) was let go from her job. I am at a crossroads right now and I am not sure where to go from here. I am worth a lot more than the job(s) I am being given. They are all nice people but I think my worth has been diminished. So, no you are definitely not alone when you say sometimes people just don't want to listen.
 

Monica Michele

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Nashville, TN
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Ng Emr

It is nice to hear of a fellow coder working with NextGen. I am the Coding Director and the Coding/Compliance/Clinical Content Project Manager for our company's NextGen implementation. We have done a great deal of custom template development to accommodate our physicians and workflow. I designed a template to capture our charges in a way that would make the process seemless for our doctors. Though we are not live just yet, we have many aspects in a Pre-live status. The system is great. I would love to chat with you and share some ideas. Are you aware of the relationship that NextGen is building with IMO (Intelligent Medical) for full system integration? This will be a great assisstance for physician coding.

Monica M. Mitzenmacher, CPC, CCS, CCS-P
 
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Binghamton, NY
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We had the same issue and are also on NextGen. With our EMR we found it much easier on the providers and no longer document two separate notes. The one SOAP note created must however, include the additional complaints or chronic problems as the reason for visit and each of them must have an appropriate HPI or interval hx attached to it. When we review the documentation, we will look for the HPI and the MDM to support the E&M service as a separately billable component. I have sent many records back to the provider due to know identifiable HPI or listed additional complaint when there assessment and work-up clearly reflect management of additional components.

From the system standpoint, if the visit type is set to preventive service, then when they reach the E&M Coding template, it allows them to select a secondary E&M component.
 
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meganpoelzer

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emr reply

Pam,

I totally understand your problems with the EMR. The way I see it, at least for an established patient, if there is anything other than "rountine" mentioned under HPI and addressed under A/P, this can be considered "additional work performed" especially for an established patient. An established patient OV only requires 2 of 3 key components so you can code based on the information and HPI. What does everybody else think about this?

Another issue that we have encountered with the EMR (we have used since 2004) is that exam templates were all saying "normal", for example, "skin--normal" and under 1997 guidelines, bullet points can only be counted if there are specifics, for example, "skin--no lesions or rashes". Our providers had to redo all of their templates in order to comply with these guidelines.

Megan Barber, CPC
 

Joannehav

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I am very computer saavy (AAS in computer science), and just finishiing my coding cert., and I can tell you that the better the software product, the better the outcome. The problem lies here. If you don't know anything about software, and you're having to "pick" a product, then you're at the mercy of the salesman (vendor),, and maybe recommendations from others(they may not have been saavy, maybe they lucked out). Either way it's tough. One big reason...how can you ask the questions you need to ask if you dont understand the concept. OR, you didin't know there would be a snafu until AFTER you purchased it. Suggestion, write down everything the software doesn't pick up or allow for. Trust me, you'll be replacing this software in a few years. Why? Because the vendors will begin to get the big picture and make better software that takes up the current issues. Is this helpful? Hold you vendor accountable and ask the questions! With software comes technical assistance!
 

Joannehav

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EMR Software/Vendor Assistance and Tech Tips

OK,
I am new to themedical field (coding), but I was a PC tech in my previous life. I am hoping this helps those of you who aren't quite saavy on computer speak and software. PLEASE let me know, I trying to find my niche out here and thinking that it may be in the EMR field.
Remember that having to buy something that you're not familair with puts you at a disadvantage. Researching is helpful, but only if you have the time, AND if you don't understand how a product works, you can't possibly ask the right questions. Right?! Being at a disadvange is no good for you, but great for the salesman. One thing you want right up front is technical support. Software should always come with such. Secondly, always ask for the beta. Try it before you buy it! This gives you an opportunity to see if the software meets the needs in your particular setting. Beta, Beta,, Beta. Ever shop on line for software and if you do, there is almost always a free trial period. Know that the software available will become more adaptable to more and more varied setting becuase these vendors will hear the concerns of their customers and make appropriate changes to the program. It's important then that you not wait until you're under the gun to purchase so you have time to investigate. YOU are the one that will have to deal with it day after day.
 

Joannehav

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Having all your office's templates on hand when purchasing EMR software is essential. Creating templates are essential especially as a work around if you're software doesn't incorporate everything you need in your particular setting.
 

radcock

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EMR for 2 visits

As I read below, what I do is create two encounters for same DOS using one for S/I sick visit and the other for well ck etc. Nextgen will ask do you want to create another visit for same DOS and all you do is ck yes and it will bring it up for you to start.
 

Pam Brooks

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Since I originally posted this query, we've come light years away from this issue. NextGen will allow two codes (preventive and sick) to be billed on the same encounter, but we did have to set up very specific criteria for our physicians to support the medical necessity of the two codes.

Thanks to everyone for their suggestions. Pam
 

KellyLR

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La Plata, MD
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Emr's

Been dancing around with EMR's and have tried several in different physician offices and have noticed that some are better than others. EPIC is great but very expensive for a physician and geared more toward hospitals, NextGen, I do not have knowledge of. But I know one thing. I wouldn't want to create template for the software to process when the software system should have that for you already. I have a thousand things to do everyday. Creating software fixes is not on my list. For Web based EMR I recommend Antek Healthware they are great and have excellent customer support after you buy the package and it is custom to your needs right away not after. I believe they even have a BETA download for you to try to see if you like. And it is fairly priced. But there is a problem with Web if it goes down, well....Lynix systems are the best though. Be careful of the sales people. Remember they are doing it for the sale and will tell you ANYTHING to get your business. I speak from experience on this one and EMR's.

This is what I have experienced out there...Good Luck!
 
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KKMeeks

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EMR's

I am replying specifically to the post from KellyLR in which she stated
"Be careful of the sales people. Remember they are doing it for the sale and will tell you ANYTHING to get your business. I speak from experience on this one and EMR's."

I have sold and serviced EMR's for many years. In the sales cycle I have NEVER told a client what they want to hearif the system won't bend to the practice's specifications, I am not afraid to say so. It is unfortunate that you would be so general in your term of salespeople. While sales are important to us, I would rather not sell to a prospect if I know the product wouldn't meet expectations. At the end of the day, though, it is the decision makers responsibility to ask the questions of the salespeople-we are not mind readers.

Sorry if I offended....

Kelly
 

Pam Brooks

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But I know one thing. I wouldn't want to create template for the software to process when the software system should have that for you already.
Well, having worked with more than one EMR and billing software products, I can tell you that none of these products always work efficiently right out of the box. Our facility has a team of nine IS specialists who are dedicated to our EPM/EMR system, and even if your physicians hand-pick the software you ultimately purchase, there will be elements that they are unhappy with. Most software can be customized, but in doing that, you 'own" the templates, and your upgrades don't go as smoothly. The biggest issues we have are with trying to develop seamless integration between our EMR and our billing process. NextGen is one of the premiere medical practice software companies in the nation, and we've pushed this software about as far as anyone in the country, and like I said above, it's a full-time job for nine people, not to mention the other 500+ of us that use it on a daily basis. In a small private practice, where cost and resources are a factor, the risk of inaccurate and non-compliant EMR documentation is huge, because they can't afford dedicated IS people or expensive consultants. Any coder who wants job security should make it a point to familiarize themselves with their software and make themselves the go-to person, because the EMR is not going away! :)
 

KellyLR

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Rebutal to KKMeeks

My apologies if what I commented on ruffle your feathers. I was an Engineer for 20 years before I jumped off into this and I have bought lots of software over the years for companies I have either consulted for and or have fixed their software. In this field, searching for EMR software i have found to be misleading. Let me give an example, and it was true. The company we will call X. I contacted X one day. Spoke with the sales person who gave me a price right away and what I could get with each package. Couldn't tell me anything other than the highlights of what the software did. Even sat through a demo online at the time. I immediately asked for the software engineer, and when she called me back, I started asking questions about transaction transfer, etc. Once i got the info I needed, I was much better off going on down the road. This lady understood what I was getting at. I settled for the best I could find without breaking the budget I was given to deal with. I'm not saying that the EMR's are inept. But it is $$ based. What I said was just what I said "Be Aware."
 

moinsf

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Emr

I agree with Pam Brooks. I work in a community health clinic system that is going with Next Gen. We are in the middle of "going live" at all of our sites. No EMR software is perfect and there are problems when templates are employed. The best thing to do now is to learn how to audit an EMR and provide education to providers who use the EMR.
 

raidaste

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We are currently using Eclinical Works EMR. It has some really good points but some really bad ones as well. The EMR allows providers to just point and click and sometimes that's a really bad thing. It's too easy for them to do and so sometimes documentation doesn't make sense. As in the note prior about the pain in HPI and then no pain in other area. I get that all the time and I have to notify providers about it. They're catching on to some of the common mistakes but not enough if you ask me. We've had this same software for 3 yrs and I'm still finding things.:eek:
 
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NextGen is not user friendly and has numerous disadvantages, a very poor software selection in my opinion. I am the Medical Coding & Billing Coordinator at Sussex County Community College in NJ. In the process of selecting an EMR software program for my students last year I chose Medcin EMR software, however this year, after much reseach, I have switched to SpringCharts by Bryron Hamilton. I was extremely impressed with the product and the fact that he invented Medisoft - the basis for almost all medical managment software years ago. SpringChart is CHIIT certified by the federal government and is an exceptional software product. My students love it since it is so user friendly and comprehensive. If you are interested go to http://www.springmedical.com/ for a look-see. My program is known for the high level of technology we provide our students and this software satisfies my level of superior requirements. My students go out to their practicums with a MUCH higher level of coding expertise and EMR technology than the coders actually out in the field. Because of that, and the fact that we are AHIMA approved, I have a 100% CPC and CCA Exam Passing Rate and 100% job placement.

I am currently preparing a new program proposal introductory certificate in Healthcare Informatics - anyone interested in this please contact me at bstaudinger@sussex.edu

Thank you.
Bernice Staudinger
SCCC
973-200-2272
 
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jenpickett

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Cure md

I am working in an office that is in the EMR process. The doctor has chosen Cure MD for their software and was wondering if anyone else has had experience with them. We were told that we would have automated populated info taken from the scanned documents and applied to the demographics. Please elaborate if you know anything of this and what we can expect during the process. Any information would be helpful. We are all a little nervous during this transition and want to curtail any foreseen issues before they actually become issues.

Thank you....
 

Pam Brooks

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Jen, I don't have any experience with this particular software, but I suggest that you look to see if you can find an online user's group, or references from your software vendor for other practices that also use Cure MD.

Auto-populate of demographics can be anything from pushing name-only data from one program to the other, or as comprehensive as pre-loading all demographics. Depending on how sophisticated your software is, your fields between both programs will have to match up in order for your data to flow seamlessly, and since your original data is a hard copy, I'd ask CureMD for more information about what fields you can expect to transfer, and what fields you'll have to re-enter. Their assistance with this should be part of your go-live contract with them, and I wouldn't let them off the hook!

Good luck.
 
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