Ms. Tadlock said many providers are actively involved in the purchase of their EMR systems and undergo training on how to use the systems. However, the training sometimes ignores the drastic change in documentation style that comes with the new system. For example, some EMRs “enhance” provider documentation by incorporating details into E/M code selection that might have been overlooked in a traditional setting. But providers may be confused by the new prompts for information and may second-guess how much documentation is necessary to support the billed services. They may overuse prompts and enter redundant information because of this confusion.
Ms. Tadlock recommends providers review the CMS guidelines to determine how much documentation is necessary for each encounter. She emphasizes the importance of “quality” over “quantity” when documenting an encounter.
Related Articles on Coding, Billing and Collections:
AMA Opposes ICD-10 — Now What?
What Does Dr. Don Berwick’s Departure Mean for ICD-10 Implementation?
Medicare to Pay for Obesity for Screening and Counseling
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
