Today ambulatory surgery centers (ASCs) are under pressure because of economy conditions and ever changing healthcare environment. Lower reimbursement by insurance companies and greater scrutiny by regulatory bodies are few of the many threats facing their business.
To overcome these challenges ASCs are trying to identify ways to continue provide high quality of care while compliance with CMS requirements and managing their operational costs. One of the most popular ways to do so is to adopt and implement Electronic Health Record (EHR) in their daily processes. There are many other reasons why EHR is a natural progression for ASCs.
1. Ensure Compliance. The increased documentation opportunities that EHRs offer means that medical records are more complete. They contain necessary information tailored to each ASC’s needs. Templates can be designed to accurately document each type of patient encounter or procedure in order to ensure that required information is included for accurate billing and coding. Third-party payers, including government healthcare programs and commercial insurers, require the medical record document pertinent information to prove medical necessity for performed procedures.
2. Enhances Operation Room Efficiency. Ever have to wait in mid-procedure for lab results or a radiology report before proceeding with an important procedure. EHR brings logically arranged medical history and consultation reports to the operating suite. Entries can be made as events occur in the OR, making documentation a real time record of medically necessary services.
3. Improves Patient Safety. Instant access to pertinent information is essential for providing quality patient care. With EHR, medical records are available at the press of a button, anywhere in the clinic, in the office, or on mobile devices. No need to ruffle through papers to find the right lab report when the results are only a mouse click away.
4. Increase Physician and Staff Satisfaction. Documentation is the most burdensome part of delivering effective health care. EHRs allow for templated records and pre-written entries that can be tailored to each individual case. Documentation time is reduced so that physicians can do what they are trained to do: treat patients.
5. Boost Profitability. Back office operations depend on access to medical records to ensure correct coding. Most coding and billing is done electronically. Seamlessly integrate the flow of information from the surgical suite to the third-party payer. Reduce the time between when a record and completed and bills can be submitted.
6. Reduce Costs. Paper records take up valuable floor space. They are inefficient and often misfiled. How many times has a physician had to examine a patient without the paper record at hand? Eliminate the costs of supplies and storage space with an effective and efficient EHR system.
7. Easy to work with. Given a choice between paper records and EHR, nobody like paper records since it can be a challenge searching old paper records for audit and other compliance purposes and at the same time administratively putting together complete paper work is always hard for support staff.
8. Clinical Reporting and Quality Outcome Requirements. By design, an EHR is more thorough than a handwritten SOAP note. The format of a SOAP note is not abandoned, but an effectively useful EHR prompts providers to document to the highest degree of specificity. Beginning in 2014, ASCs that participate in the Ambulatory Surgical Center Quality Reporting (ASCQR) program will qualify for full annual update of their annual ASC payment rate. Accurate documentation will allow an ASC to take full advantage of the ASCQR program.
9. Increase Patient Satisfaction. Patient care improves when information is readily available to the health care team. Nurses, doctors, and ancillary staff can all review a patient’s EHR at the same time from different locations. When a patient has a question for a medical assistant, she doesn’t have to say she will have to check the paper record once the doctor has finished with it. She can check the EHR to answer the patient’s question promptly. With a stack of paper records on his or her desk, who knows when this patient’s record would make its way to the to-be-filed box and then to the shelf.
10. Mitigate Risk. In the event of a RAC audit or any question regarding questionable billing practices, a complete and integrated EHR is the best defense against charges of fraudulent intent. EHR eliminates the chance of lost or misplaced required supporting documentation. If records are requested, they can be quickly retrieved, copied and submitted to justify reasonable and necessary claims for reimbursement.
Write to us if you have any other suggestion why ASCs need EHR today.For more information about M-Scribe Billing Services please contact 888-727-4234.
The transition from ICD-9 coding to ICD-10 coding has many physicians wondering if their CCHIT certified electronic health record (EHR) software or electronic medical record (EMR) software is ICD-10 compliant. Fortunately, many vendors are prepared to offer EHR solutions that are compatible with the high degree of specificity required by the ICD-10 coding system. Here are a few tips to help you to determine if your EHR solution is ICD-10 compliant:
EHR and ICD-10
Mandatory use of ICD-10 will be required by October 2014. The new coding system demands a more robust system that can handle complex documentation. Selecting electronic health records (EHRs) and electronic medical records (EMR) to address the problem ensures that data can be manipulated easily without limitation.
Is EHR Able to Handle Comprehensive Documentation?
ICD-10 codes are more detailed and descriptive for more accurate billing and forecasting. Experts predict this will help physicians capture better data to provide a more comprehensive view of healthcare on a local and global scale. Since not all EHR applications are created equal, it is essential to assess the ability of the EHR to capture and manage complex data structures.
Here are some essential components of EHR:
Most EHRs can handle complex data definitions. Robust database solutions are required to maintain and retrieve data definitions.
The discharge summary should provide a complete view of the patient’s condition at the beginning of treatment. Data from tests, procedures and examinations must be captured and stored. The discharge summary is a part of a comprehensive solution.
EHRs should have the capability to capture data related to procedures during a hospital stay including: diagnosis prior to the procedure, procedure performed, description of the procedure and the name of the attending physician or assistant.
History and Physical (H&P)
This two-part medical report provides documentation of the patient’s past history. This is just one component of comprehensive data collection. The information gathered can be used to determine the patient’s initial treatment plan.
The consultation report is another type of data that should be captured and stored in EHRs. The tool must capture information about the patient’s medical record and also any recommendations from the consultant.
If More Documentation Needed Then is Transcription Still Relevant?
Transcription has evolved and does not resemble transcription of the past. Transcription continues to be relevant, but the method of transcription has changed. Voice recognition technology allows physicians to create narrative reports with three different options for document editing. These options consist of: medical editor modification using speech recognition, schedule self-editing and physician real-time self-editing.
Transcription has evolved to include the “once-and-done” approach. Physicians capture the data once at the point of care to make the process more streamline. In the midst of the transition, many physicians are using the blended approach which is a mix of text transcription and voice recognition transcription. The blended approach aids in the transition to ICD-10 codes.
In the meantime, physicians must ensure that their new ICD-10 software is compliant and supports voice recognition software. The new process can only streamline processes and make processes more efficient. New technologies incorporate the use of dictation templates to facilitate efficient reporting.
Some physicians are resistant to change and are avoiding the transition from ICD-9 to ICD-10. They are confused about the benefits of the ICD-10 as this article is correctly highlighting- http://www.fortherecordmag.com/archives/061812p29.shtml. The lack of knowledge leads to inferior EHR systems that deliver imperfect health information. Physicians can ease the ICD-10 implementation with an efficient EHR that will help providers select the best code to describe the patient’s medical condition.
Maintaining Compliance is Essential to Success
Physicians must ensure they are in compliance with the electronic discovery rule and maintain guidelines for EHR documentation. Maintaining compliance makes audits easier and more efficient. EHRs must be evaluated to select software that is both compliant and comprehensive.
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All “covered entities”—as defined by the Health Insurance Portability and Accountability Act of 1996 (HIPAA)—are required to adopt ICD-10 codes for use in all HIPAA transactions with dates of service on or after the October 1, 2014 compliance date. For HIPAA inpatient claims, ICD-10 diagnosis and procedure codes are required for all inpatient stays with discharge dates on or after October 1, 2014. Transition to ICD-10 does not directly affect provider use of the Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) codes.
Some other facts about ICD-10:
Coders will have use thousands of new codes
Diseases aren’t changing. The codes on how to report them are changing to become more specific and dependable. Users won’t necessarily have to learn more new codes, but they will have to change ingrained habits on how to access more powerful and specific codes.
Coders will need to change their processes, workflow and beef up their knowledge of anatomy, and physicians will be required to shore up clinical documentation with more specific nomenclature in documentation that translates to effective coding. Vague descriptions of conditions by physicians and rote memorization by coders—or guessing what they think the correct code is—will no longer suffice with ICD-10. Training for staff is critical and cannot be overstated.
ICD-10 and EHR implementation are complementing each other
Some healthcare professionals are avoiding the task of transitioning from ICD-9 to ICD-10 because they are confused about priorities and feel caught between competing initiatives. But implementing EHRs, attesting to meaningful use, and transitioning to ICD-10 are closely aligned and complement each other. These initiatives together should be considered as a comprehensive package to improve documentation efforts.
A speedy, efficient EHR can ease the ICD-10 implementation. EHRs may streamline the coding process by functioning as coding crib sheets, providing boundaries and helping providers select the most appropriate code. Transitioning to ICD-10 ensures that EHRs, value-based reimbursement, and meaningful use incentive programs all speak the same language.
Detailed medical record documentation will be the Key for ICD-10 to be implemented
As with ICD-9-CM, ICD-10-CM/PCS codes should be based on medical record documentation. While documentation supporting accurate and specific codes will result in higher-quality data, nonspecific codes are still available for use when documentation doesn’t support a higher level of specificity. As demonstrated by the American Hospital Association/American Health Information Management Association field testing study, much of the detail contained in ICD-10-CM is already in medical record documentation but is not currently needed for ICD-9-CM coding.
ICD-10-CM-based super bills will not be long or complex
Practices may continue to create super bills that contain the most common diagnosis codes used in their practice. ICD-10-CM-based super bills will not necessarily be longer or more complex than ICD-9-CM-based super bills. Neither currently-used super bills nor ICD-10-CM-based super bills provide all possible code options for many conditions. The super bill conversion process includes:
- Conducting a review that includes removing rarely used codes; and
- Cross walking common codes from ICD-9-CM to ICD-10-CM, which can be accomplished by looking up codes in the ICD-10-CM code book or using the General Equivalence Mappings (GEM).
ICD-10 has great benefits for stakeholders
Everyone wins with ICD-10—from providers to patients. As mentioned, the specificity of ICD-10 is its forte. Because it facilitates more accurate diagnoses, ICD-10 enhances patient outcomes, supplements evidence-based research, and improves public health tracking and population health analysis.
As providers become more accountable for patient outcomes, less ambiguous coding will help specify reasons for patient noncompliance. Enhanced documentation of a patient’s condition will improve shared data with health information exchanges, facilitate auditing efforts, and decrease fraud and abuse. The ability to leverage ICD-10’s greater granularity will help increase reimbursement and establish more effective processes.
Time is perfect for the transition to ICD-10
Conversion from ICD-9 to ICD-10 CMS is long overdue. ICD-9 was created in 1979—before the identification of many diagnostic and technological developments that have occurred in the past 30 years. We need coding that matches recent medical discoveries and aligns with other developed countries that adopted ICD-10 years ago.
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HIPAA X12 standard - version 5010 is a new standard that regulates the electronic transmission of specific healthcare transactions.
Covered entities, such as healthplans, health care clearinghouses, and health care providers, are required to conform to HIPAA 5010 standards. The compliance date for use of these standards is January 1, 2012. It is necessary to implement the new standard to prepare for the transition to ICD-10-CM and ICD-10-PCS. The compliance date for ICD-10 is October 1, 2014.
As a provider should I care?
HIPAA 5010 can be understood as an upgrade on the existing form of HIPAA rather than a significant change in the way HIPAA-defined benchmarks have been defined for processing transactions in the healthcare industry. The changes put forth as a part of HIPAA 5010 were being anticipated for some time since the existing standards of HIPAA were beginning to seem a bit outdated. HIPAA 5010 has been created in such manner that the forthcoming changes in the revised medical billing/coding data of ICD-
10-CM & ICD-10-PCS will be accommodated by all covered entities in a better manner. These changes in the coding systems are scheduled to be made effective from October 1, 2014 and thus, adoption of HIPAA 5010 will mean that all covered entities and their business associates have sufficient time and proper understanding of the altered coding systems. However, this doesn’t mean that HIPAA 5010 doesn’t present any challenges to the US healthcare industry.
Whats the difference between old HIPAA 4010A1 and new HIPAA 5010?
There are some major differences between HIPAA 5010 Rule and the existing, HIPAA 4010A1 standards. As a result, the entire process of upgrading to HIPAA 5010 could be a bit time consuming. However, this slight deterrent is largely negated by the fact that the adoption of HIPAA 5010 will improve the quality of transactions in many ways. The most notable advantages would be the removal of ambiguities in the existing healthcare information processing systems, ensuring more consistency in healthcare transactions. This will also help to graduate towards adopting NPI regulations in a more comprehensive manner and easier elimination of patient data that has no relevance. Covered entities or business entities in the US healthcare industry shouldn’t feel threatened by the introduction of HIPAA 5010 since it doesn’t put forth a financial stress on their operations. These entities merely need to review their existing systems and that of their business partners and understand how HIPAA 5010-defined standards can be adopted, i.e. ensuring HIPAA 5010 compliance in the most undemanding manner is possible.
What do I need to do to prepare for ANSI 5010 compliance?
Speak with your current practice management system vendor. Software vendors are not covered “entities” and therefore, not responsible for compliance. However, your compliance depends on your vendor’s implementation of compliant products.
Ask your vendor(s):
- Will you upgrade your current system to accommodate Versions 5010 transactions?
- Will the upgrade include acknowledgement of transactions 277CA and 999?
- Will the upgrade include a “readable” error report produced from 277CA and 999 transactions?
- When will you be capable of supporting Version 5010 transactions?
- Will you be able to support both Version 4010A1 and 5010 transactions concurrently?
- When will the current system accommodate both the data collection and transactions conduction for Version 5010?
- When will the upgrades be available and will there be a charge?
- When will the software installation to the systems be completed? Before January 1, 2012?
- Will there be adequate lead time to test the new software prior to the January 1, 2012 compliance date?
Note: If your current system cannot handle 5010 transactions or your vendor isn’t planning on updating their system to accommodate 5010 transactions, you may have to purchase new software. If so, you’ll need to set aside enough time to research different programs and an appropriate budget for paying for the cost of new software or a system.
It is very important that your vendor completes the installation of system upgrades in your practice early enough to allow to test the transaction process with your electronic trading partners (billing service, clearinghouse, health plan, etc.). You will also want to plan appropriately in advance for training your staff.
2. Speak with your clearinghouses, billing services and health insurance payers. You’ll want to ask them:
- Are you planning to upgrade your systems to accommodate Version 5010 transactions?
- When will you complete the upgrades?
- Will you change your fees for Versions 5010 transactions?
- Will we need to register in order to conduct 5010 transactions? How?
- When can we send you our test transactions to ensure the system works accurately?
Note: Based on the responses to the above questions, you will know if your clearinghouses and billing service can continue to support your business. This information will help you plan budget needs and help develop a timeframe for testing and implementing. It is essential that you contact all of your payers, billing services and clearinghouses to ensure your transition to 5010 will run without payment interruptions.
M-Scribe uses 5010 complaint web based practice managment software which works with windows and mac operating systems.
For more information about M-Scribe Billing Services please contact 888-727-4234.