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

ASC Survival Depends on Implementation of an EHR

Posted by Harold Gibson on Wed, Dec 12, 2012

ASCs ChallengesToday 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.

Tags: RAC Audit, EHR, HIPAA, Electronic Health Record

Medical Documentation and Coding Demand Will Increase with ICD-10

Posted by Harold Gibson on Fri, Aug 31, 2012

M-Scribe Medical CoderThe world of medical documentation and medical coding is extensive and always changing. The change that has the medical field buzzing right now is the transition from ICD-9 to ICD-10 (International Classification of Diseases – Version 10). Currently, health care facilities use ICD-9 for documentation and coding, but by October of 2014, every facility must abide by the new system. These new changes will increase the need for skilled medical transcription and medical coding. It also brings the expertise of these two jobs closer and will merge at some point in the future.

Why Will the Demand for Transcription and Coding increase?

For healthcare employees already working as a medical transcriptionist or medical coder, they don't need to worry about these changes affecting their chances of employment. The truth is that the need for these highly skilled workers will actually increase with the implementation of ICD-10. 

One of the main reasons for the increase of work is that the new book of codes is a lot more specific than ICD-9. For instance, in ICD-9, the code for a burn on the left arm is the same code as a burn on the right arm. While this may not matter to the insurance company, it does matter to the treating physician, the patient and the transcription. There are not numerous new diseases in the latest manual, but it will have over 70,000 codes listed. They will convert to seven digits, instead of five (as seen in the past). The increase in codes and length of codes will help the medical coder be more specific.

There is no substitute for an intelligent human mind — the fear that medical transcription will be obsolete after the new implementation date is unfounded. Both transcriptionists and coders will actually have to work harder and attend additional training to become compliant. The new system may be confusing and overwhelming to those who have worked on ICD-9 for years. As these older employees leave the workforce, fresh new recruits will be needed. 

Importance of Implementing Electronic Health Records (EHRs) From an ICD-10 Prospective

In order to be compliant with the new rules, healthcare facilities will find that having an efficient EHR (electronic health record) system in place will be a huge benefit. There are still thousands of private practices that have not made the switch to electronic medical records, but this will hurt them when they face compliance issues with the new coding regulations. 

By implementing an easy to use and efficient EHR, the transition to ICD-10 will be a lot smoother. If a facility currently does not use computers for maintaining records, they should consider doing this as soon as possible, to be ready for upcoming coding and documentation changes. 

The reason an EHR is so important is because it helps streamline the coding process. It is much easier to use a search function on a computer than trying to pore through hundreds of pages in a patient’s chart to find information. To determine whether an injury was on the left or right side of the body, for example, the coder can simply search for this terminology within the patient’s electronic record. To find this information in a paper chart wastes hours of valuable time. 

How Will the New System Help Medical Transcription?

It may be true the new system will mean less hours of transcribing work, but it doesn’t appear transcription will become obsolete. In fact, those that choose to stay in the field and learn ICD-10 coding will be rewarded with even more hours of transcribing work. 

Because ICD-10 demands greater detail, physicians will have to provide comprehensive information in their records. This translates into more words for the transcription, which equals greater pay. Also, the increased need for transcription with coding expertise will mean better rewarding opportunities.

To learn about our services, please visit Medical Documentation and ICD-10.

Tags: ICD-10, ICD-10 Coding, medical coding, Medical Billing, EHR, ICD-9, Medical Documentation, Electronic Health Record, CDI Specialist

Medical Billing Services become economical for Dermatology practices

Posted by Harold Gibson on Wed, Aug 15, 2012

M-Scribe Billing Service

Medical billing is now more affordable than ever for most medical practices however billing cost could be high for some specialties like Dermatology and Plastic Surgery practices where coding can be complicated because of different use of modifiers, dummy codes and higher co-payments involvement. M-Scribe offers a medical billing service for dermatology practices at rates that undercut all of their industry competitors. While most industry leaders charge 8-10% of total collections, M-Scribe offers a low overhead; web based billing service that reduces costs for dermatology medical practices. A flat fee is all you will ever be charged by M-Scribe's medical billing service—a discount of 50-60% over the other leading providers. With unique customizable solution, your office no longer needs to worry about high billing and collections costs.

Efficient Process makes the difference

Industry experts say the first 80% of payments are easy to collect.  It is the next 20% that are difficult to collect. 

We understand every little process matters to collect that extra 20% for example paper work is most important part of your practice and in every little process involved in coding. So instead of sending paper documents to us, we provide bi-direction industrial scanner for FREE. You can save time and money by using high-speed scanners to digitize your billing information. This rapid turnaround time ensures that your bills are sent out promptly and without errors that could lead to frustrated patients at the end.

Full Legally and Ethically Entitled Reimbursement

In 2011 we coded approximately 2.9 million codes, registered 3.7 million patient accounts and 5.16 million charges in terms of counts. We have entered $955.9 million charges and collected $438 million. We have audited, trained and protected more than 1,800 physicians.

All the claims are processed within the same-day; avoiding unnecessary delays helps us increase your profits by 10 to 20 percent while lowering the cost of billing as compared to either in-house or other medical billing services.

Free Specialty EMR

M-Scribe isn't only a medical billing service; dermatology practices can also enjoy all the stimulus benefits by using one of the leading EMR in the country absolutely FREE. At no cost to you we are providing best features like Labs - quickly connect with your choice of laboratories, e-Prescribing - send eprescription to over 70,000 pharmacies, Scheduling -schedule patient visits in our EMR with one click, Charting- customize templates to fit your practice and specialty, Billing- manage billing alongside our electronic medical records (EMRs).

Best Use of Technology

M-Scribe medical billing software effectively manages the process between providers, insurance companies, clearing houses and patients. This helps us to collect faster from insurance companies and patients. Dermatology practices with higher co-payment patients’ timely manner invoicing and regular follow-ups are very critical. Our web-based software is superior to traditional medical billing software’s because it's more convenient and faster to setup. It provides all of the features and functionality that you need for your practice. We are managing many dermatology practices with insurance payment situations in different states.

Experienced Coding Team

Delivering everyday accurate billing is not only depends on capturing accurate and timely medical data but also on how efficiently using proper coding. Our certified dermatology experienced coders possess in-depth knowledge to understand health record’s content in order to find information to support or provide specificity for coding. Our coders are trained in the anatomy and physiology of the human body and disease processes in order to understand the etiology, pathology, symptoms, signs, diagnostic studies, treatment modalities, and prognosis of diseases and procedures to be coded. Their daily job entails much more than simply locating diagnostic and procedural phrases in the coding manuals or with encoder software. They have knowledge of disease processes and procedural techniques to consistently apply the correct codes. Our medical coding professionals work as integral part of a dedicated billing team to achieve the best results for you.

M-Scribe Delivers Best

The reason M-Scribe ensures high quality work at a low price is simple: most companies offering a similar medical billing service simply don't have the experienced dermatology specific coders and technological know-how or the information infrastructure to lower their costs. M-Scribe dermatology experienced coders and uses technology in a way that streamlines billing processes— and that helps you get collected every dollar ethically and legally entitled in this ever changing coding and billing world.

Tags: medical coding, Medical Billing, EHR, ICD-9, Dermatology Billing, Medical Billing Service, Electronic Health Record

Difference Between Medical Billing Software and EHR

Posted by Harold Gibson on Wed, Mar 21, 2012


PracticeFusion emr resized 600Medical billing and EHR software systems are often designed to have overlapping features that improve the functionality and usability of the systems in order to make them a “one-stop-solution” for a practice’s medical IT needs. As a result, medical billing software and EMRs end up being interchangeably used discounting the primary objectives of each of the systems.

Many EHR companies are going the whole way to provide doctors with a single, comprehensive solution that will help them achieve Meaningful Use by incorporating crucial features like clinical notes, patient information and history, medication/prescription/drug allergies, diagnosis/treatments/procedures, patient scheduling, appointment reminders, e-prescribing, electronically available results, scans and reports, patient education resources, clinical decision support as well as full-fledged medical billing programs.

Specialized medical billing software on the other hand, is particularly programmed to maintain and keep detailed records of tests, procedures, examinations, diagnoses and treatments conducted on patients. It combines this medical information with the patient’s policy details to formulate a complete medical record that is used to generate bills.

The software electronically submits these bills to the patient as well as the health insurance company for payment. Before a bill can be submitted to the policy provider, it has to be coded based on Current Procedural Terminology (CPT) and International Classification of Diseases (ICD-9/ICD-10) protocols. Medical billing software systems are programmed to automatically assign these codes based on the patient’s medical record. After reviewing the bill, the insurance company sends the appropriate payment (or notice of denial) notifying the patient and practitioner via an Explanation of Benefits (EOB) letter which is added to the patient’s medical billing record by the software. In case of a dispute, rectification of bills with errors or missing information and follow up on claims, the software will update the patient’s medical record and billing details with the revised information.

Medical billing and coding software is thus equipped to seamlessly and accurately handle all complex processes and correspondence involved in medical billing.

A typical base package of medical billing software would contain features that are restricted to medical billing and accounting functions like patient recordkeeping, claims processing, electronic claims submission, receivables management, patient billing and accounting integration. However, many software providers extend their scope to include features like practice management, scheduling and other administrative and clinical functions that are generally a part of EHR software systems. 

Therefore, the difference between medical billing software and an EHR is that of core functionality. While medical billing software focuses on a practice’s medical billing procedures and billing-related administrative and financial processesfeatures of an EHR are primarily concentrated on clinical functions, records and outcomes.

Medical billing software may serve clinical EHR functions in addition to electronic billing and coding for greater versatility. The same is true for EHR systems that incorporate specialized medical billing and coding program features to supplement their clinical applications.

Tags: EHR, Electronic Health Record, Practice Fusion

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