Electronic Medical Records (EMR/EHR) - Articles

Medical Coding: Why Is An 'Easier' System So Complicated?
January 16th, 2023 - Find-A-Code
Believe it or not, there was a time in this country when paying for medical care was fairly simple. Your doctor rendered services for which you paid at the time of the visit. Medical insurance only offered catastrophic coverage for major medical events. Those were simpler days.
2023 Should Be a Time for Change for the Electronic Medical Record
January 9th, 2023 - Erica E. Remer
The EHR is no longer in its infancy; it is exiting its “terrible twos” stage and growing up. It’s a new year, and welcome, 2023! When I still practiced clinically, I once got a job as an emergency physician at a brand-new hospital. I was really excited, because...

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How Extensions to the COVID-19 Public Health Emergency Affect Healthcare Reimbursement
June 28th, 2022 - Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Providers need to begin preparations for how to handle a return to pre-COVID-19 public health emergency (PHE) policies. As the saying goes, "you can't put the rabbit back in the hat." Some COVID-19 PHE policies are so well liked it will be very difficult for the government to return to pre-COVID-19 policies. For now, we have at least the promise of a 60-day notice to all governors precipitating the end of the PHE.
What did I do today?
December 13th, 2019 - Namas
What did I do today? Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...
A United Approach
June 14th, 2019 - Namas
A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
HHS Proposes Significant Changes to Patient Access Rules
February 11th, 2019 - Wyn Staheli, Director of Research
In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...
Patients Over Paperwork?! We have Great News!
July 18th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Spend more time with patients and less time documenting? Great Concept! Document meaningful information? Sound good? CMS is proposing just that! CMS released a new proposal July 12, 2018, focused on streamlining clinician billing and expanding access to high-quality care. The goal is to improve and restore the doctor-patient relationship, modernize Medicare ...
Patient With Complex Needs
December 29th, 2017 - Kelly Ogle, BSDH, MIOP, CMPM, CHOP
In each practice, there are patients who present with a multitude of problems. These problems can range from the smallest of symptoms to the more complex illnesses.....
Auditing the Use of a Scribe
December 1st, 2017 - Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT
A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider......
Acronyms and Abbreviations: When You Fall into the Grey Area
October 6th, 2017 - Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before. The language is unclear, the acronym(s) could mean so many different things, and it's hard to get a straight answer about whether or not it's supported higher or lower....
Medicare Announces New Cards to Be Issued
August 17th, 2017 - ChiroCode
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars. Personal identity theft affects a large ...
Medicaid EHR Incentive
February 6th, 2017 - Wyn Staheli
The Medicare and Medicaid incentive programs are different. The Medicare EHR incentive program has been incorporated into the new Quality Payment Program (QPP). However, providers may be unaware that there is still a Medicaid EHR incentive program. The time period for signing up for the Medicaid EHR incentive program ended in 2016. ...
Psychotherapy Notes Provision of HIPAA
February 2nd, 2017 - Wyn Staheli
Of special interest to all behavioral health practitioners (both Covered Entities and NON-covered entities) is HIPAA's provision for psychotherapy notes. The privacy rule recognizes that psychotherapy notes need more protection than other types of PHI. Even if you are not a covered entity, we recommend understanding and implementing office procedures ...
ICD-10 Roundup: Private Practice Radiologists Share How Prepared They Were for ICD-10
June 7th, 2016 - Practice Suite
In October 2015, the entire U.S. medical community made a controversial shift to the 10th Edition of International Classification of Diseases (ICD-10). The road to ICD-10 was marked with multiple delays, primarily due to concerns that physician-owned practices were not prepared for the ...
Don’t expect beneficiaries to pick up the slack for PQRS, EHR cuts
December 4th, 2014 - Scott Kraft
2015 is a big year for payment adjustments for providers who’ve failed to take part in CMS incentive programs for electronic health records (EHR) meaningful use, e-prescribing and the Physician Quality Reporting System (PQRS). It’s the year that CMS goes from dangling the carrot...
Meaningful use phase 2 coming in 2014
October 1st, 2013 - Scott Kraft
Earning a Medicare electronic health record (EHR) bonus payment requires you to do more than simply buy and install an EHR system. CMS expects you to use the system, and has set up a series of tasks you must accomplish, known as establishing meaningful use. Currently, to achieve a bonus...
How to Manage a Hospital, 101
May 1st, 2013 - Robert Jordshaugen
CEO - stop "Making decisions." If the data and metrics are correct, the decisions are self evident. Spend time instead developing your team, your culture of communication, and ensuring that you are measuring the right activities. Stop managing departments and start managing patients. The...
EMRs - Coding and Compliance Concerns
April 24th, 2013 - Allison Singer, CPC
Introduction The past year has been an exciting time for healthcare professionals, bringing more changes, opportunities and challenges than ever before. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which is a portion of the American Recovery and Reinvestment Act...
Graphical Coding as part of EMR clinical workflow
March 22nd, 2013 - Robert Jordshaugen
The way to ensure a high performing EMR implementation is to fundamentally rethink processes to match what is technologically appropriate, rather than automating existing workflows. Instead of using the existing HIT EMR systems from the major vendors as the workflow driver, start with a sample of...
ROS Checklist
April 22nd, 2009 - Rikki Runyon
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ...
E-Prescribing and Medicare Bonus Payments
April 1st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE Question Our doctors want to begin e-prescribing in order to get the Medicare bonus payment. How much is the bonus payment, and how do we let Medicare know that we are e-prescribing? Answer The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)...
Incentives for implementing an Electronic Health Record
March 1st, 2009 - Codapedia Editor
The stimulus package passed by Congress in early January, 2009, provides financial incentives for implementing and using en Electronic Health Record (EHR or EMR for Electronic Medical Record.) These incentives would be available for physicians starting in 2011 or 2012. The incentives start big, and...

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