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Electronic Medical Records

  1. Default EMR - Allscripts
    Medical Coding Books
    Is anyone currently using Version 11 of Allscripts?

  2. Unhappy 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.

  3. #13
    Nashville, TN
    Default 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

  4. Default
    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.
    Last edited by denisebecker; 11-29-2007 at 11:13 AM.

  5. Default emr reply

    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

  6. Default
    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 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!

  7. Wink EMR Software/Vendor Assistance and Tech Tips
    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.

  8. Default
    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.

  9. Smile 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.

  10. #20
    Dover Seacoast New Hampshire
    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
    Pam Brooks, MHA, COC, PCS, CPC, AAPC Fellow
    Coding Manager
    Wentworth-Douglass Hospital
    Dover, NH 03820

    If you can dream it, you can do it. Walt Disney

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