Medical Billing, Coding and Documentation Services

Future of Medical Documentation and Coding in the World of EHR

Posted by Alec Winfrey on Mon, Feb 11, 2013

Medical Documentation and CodingEHR documentation — what goes in and how it comes out — it’s all in the ingredients.

In a bake-off between two cakes, the choice may be clear as to what you like (chocolate of course). The same has been true in the past when evaluating software or services, as everyone wants to be assured they selected the best-of-breed. Because of the makeup or construction, the EHR can be a mixture consisting of inputs, talents, proficiencies, and yes, even hardware and software sets. Choosing a true best-of-breed in this environment may require to step backward and understand exactly what needs to be accomplished. Armed with perspective and some defining objectives, it becomes clear that creating and utilizing a medical record should be an integrated process. 

Technology in both hardware and software now allow services to combine skill sets and proficiencies together — the economics can be significant. By coupling documentation with coding, then blended with billing, and lastly with collections, you not only have synergy, you have complete functionality. It’s the ultimate combination of breeds, the All American mute or All American EHR. 

Much of the information that goes into the EHR has succumbed to the new technology that is immersed with automated systems. The business of medical transcription is struggling to exist with voice recognition software and EHR offers. While medical coding is moving towards automated coding capture software tools, it is usually based on the medical transcription or documentation and other patient related information available in EHR or Electronic Data Interchange Exchanges (EDI). In a new-age world of technological advances, is it wise to have healthcare documentation and coding combined and automated without human expertise, or is there still a need for the human specialties of reason and logic?

Voice recognition software for transcription is specifically designed to capture English and medical terminologies from a variety of accents and dialects. Unfortunately, many healthcare records travel straight from this software into the EHR without passing the hands and eyes of a medical language specialist. The voice recognition software is not very reliable as a stand-alone tool because it cannot decipher and correctly document medical terminology that is questionable. Physicians who are using such voice recognition tools to finish their charts enter them hurriedly into the EHR — these tools often require slow and accurate dictation to be recognized by a human accent and to make sense out of it. They have to treat patient ailments and may not always be conscious of what is being dictated (or how fast they are going). Medical transcription is a specialty of language. While editing is a helpful tool in the field, it should never be relied upon as the sole contributor to documentation.

Medical coding is also a highly specialized position. Without the reasoning of the human being who possesses knowledge of procedure and diagnosis codes (as well as insurance regulations), it is far too easy for an automated system to incorrectly code what it picks up in a medical document. For example, if a document indicates a patient started to undergo chemotherapy according to a particular protocol, but therapy was stopped due to low blood counts or illness, the system will still likely generate a bill for the chemotherapy. This not only causes the insurance company trouble, but also adds additional difficulty to the patient's list of worries.

Even in today's advanced healthcare industry, it is important to make sure the integrity of the medical records are not compromised through the reliance of automated technology. In order to ensure this, there must be human expertise involved as these records follow people throughout their entire lives. Since correcting existing errors in medical records can be an extremely difficult and tedious process, it is far safer to ensure quality documentation by employing specialists in both medical language and coding. 

In a world saturated with technological advancements, the best way to manage the current demands without sacrificing the quality or the integrity of the medical record is to combine the workforces and expertise of Medical Transcription and Medical Coding specialties with voice recognition and coding tools.

Now we can look at the process and move away from individual decision-making regarding technology (as well as the burdens of making all pieces work as one). Seek a service that combines all of these elements and evaluate how to best implement this best of breed.

Tags: medical coding, Medical Billing, EHR, medical transcription, Medical Documentation, Electronic Health Record

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