Using electronic medical records (EMRs) in your practice comes with umpteen benefits – Be it saving time, creating legible documentation or sharing history with fellow providers. However, relying too heavily on EMRs could come with its own pitfalls.

Heed these three tips to know where your EMR system could be leading you astray:

Exam Documentation Does Not Carry Over

You may be relying on your EMR too much if it constantly shows E/M documentation that’s robust in one section and not so in another (such as exam). To cite an example, an auditor down-coded many of a practice’s E/M claims due to empty ‘physical exam’ sections in the documentation. The practice explained that the EMR vendor had told them that patients being seen for established problems already have documentation on file and that the EMR will carry it over from one visit to the next. But the truth is carrying information over for follow-ups is permissible for some degree of past medical, family, and social history and not for an exam.

An EMR’s Notation of Time Spent is Not Enough

One of the advantages of EMRs is they normally record the date and time that information is put in such as “Total time: 36 mins, 15 secs.” Many practices use this time calculation to choose an E/M code. For instance, if these practices are reporting 99214 (Office or other outpatient visit … Typically, 25 minutes are spent face-to-face …) for the visits, using the logic that CPT^® allows you to code E/M services based on time. But the truth is the key to billing based on time is that counseling and/or coordination of care must dominate the visit. It accounts for over half of the time spent.

Use your EMR’s Code Selection as Only a Suggestion

The E/M code suggestions offered by your EMR can be helpful; but that does not mean you can use that to justify all high-level codes. Medical necessity is the important criterion for payment in addition to the individual requirements of a CPT^® code. Moreover, according to the 1995 E/M guidelines, “The documentation of each patient encounter should include: reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.”

Converting from paper records to an electronic medical record system (EMR) is a huge effort and may leave you wondering whether making the change is really worth it. Check out these five reasons why experts urge you to take the ‘electronic’ way.

Boost for Quality of Care

Electronic systems often provide access to a database of national outcomes data from users of the same software – which is essential for measuring and improving your care.

One more advantage is that many of the systems will connect you to research the best practices for treating certain diagnoses. Therefore an EMR can really help drive evidence-based practice. Electronic systems can also help standardize your care. For instance, if your practice sees the same diagnoses quite often, you could bill shells for certain care plans so that you have some standardization of care to begin with.

Clients Anticipate EMRs

Whoever is buying your services wants to see a modern operation. Switching to an EMR is important because when a customer wants you as the vendor, you need to continue to meet the customer’s expectation. Moreover, a more modern feel in your clinic may help bring in patients who are shopping around for a physician/therapist or are alert to small details like being current.

Errors are Caught Before They Shows on Your Claims  

If you forgot to include a start date on your plan of care or missed a CCI edit, electronic billing and documentation systems can catch these types of mistakes before they cost you money.

Tip: For billing, compliance or any other purpose, you can program a documentation system to get users to answer certain questions prior to proceeding. You can also save yourself the hassle of certain HIPAA violations too.

More Cash and Perks        

The federal government had launched the Health Information Technology for Economic and Clinical Health (HITECH) Act which plans to pay eligible healthcare professionals incentives for the ‘meaningful use’ of certain EMRs. Many research studies pull their data through electronic records. So if you cannot participate, you will miss opportunities for cash perks.

Easier Access Ensures Smooth Sailing

Even though implementing an EMR system is a lot of work, however, the convenience of pulling up a patient record in a matter of seconds is worth it. In fact, easy access to a patient record is important for any organization.

With the increased enforcement and higher fines as well as the $10,000-minimum penalty for “Willful Neglect” of compliance, the compliance status of your electronic health record (EHR) system now matters more than ever. But you can reduce your Health Insurance Portability and Accountability Act (HIPAA) breach dangers and stay calm about your EHRs at the same time by performing a thorough risk analysis.

Why risk analysis

Risk analysis is the cornerstone of your compliance process. Risk analysis is mandatory under the HIPAA Security Rule’s Meaningful Use and the health Information Technology for Economic and Clinical Health Act.

Whom to involve

You and your staff can perform the risk analysis; however watch out that “the risk analysis can become quite technical.”  So it’s always best to have your IT staff involved, at least partially, if not throughout. You could check out your local regional extension center that provides tools and helps perform the risk analysis and resulting mitigation.

How often to perform risk analysis

One of the big questions is how often you should perform a risk analysis. You should try to do it at least once a year. You should also perform another risk analysis anytime there is a major technological or physical change. This may include a new EHR, a new component to your EHR system or new computer network architecture.

Which areas to focus

To conduct a thorough risk analysis, you must look at important areas to reveal all the potential ways something can go haywire. More particularly, you should assess what can go wrong to affect the confidentiality, integrity or availability of the electronic protected health information.

• Confidentiality: As you know, your main concern when working with EHRs is safeguarding data from unauthorized access, breaches and leaks. According to the HHS Office of the National Coordinator for Health IT, you should ask questions such as what new ePHI have EHRs introduced into our facility, where will that ePHI reside, who will have access to EHRs, should all employees have the same level of access to EHRs, will I allow employees to have EHRs or ePHI on their mobile computing/storage devices and if so, how can we keep the data secure on those devices?

• Integrity: Another aspect of your EHR privacy and security is see to it that the data contained in the records is accurate and remains untouched by unauthorized users. To check your integrity risks, the ONC recommends that you take into consideration questions such as who will be allowed to create or modify an EHR or the ePHI contained in it, how will I know if someone has altered or deleted data in an EHR, if I participate in a HIO, how will I know whether the health information I exchanged is altered in an unauthorized manner.   You also need to ask questions such as if my EHR system allows patients to access their health record/information online, will I allow patients to modify any of the health information in their EHRs, if so what information?

Availability:  You will want to improve your patient’s access to their own medical records. But can you do it without compromising on security? To assess your availability risks, you could assess points such as how will I ensure that ePHI, regardless of where it resides, is readily available to authorized users for authorized purposes, including after normal office hours, do I have a backup strategy for EHRs in the event of an emergency, power outage or computer crash, if I participate in a HIO, does it have performance standards for network availability? Or if my EHR system allows patients online access to their health records, will I allow 24×7 access?

Where to get help

• http://www.supercoder.com/coding-newsletters/my-health-information-compliance-alert
• http://www.supercoder.com/coding-education/books/hipaa-handbook-2013
• http://www.supercoder.com/coding-newsletters/my-medicare-compliance-reimbursement-alert

This year has ushered in a lot of new codes which has potentially impacted each and every practice. Only the right resource will help you overcome all your coding and billing woes and make sure you are collecting deserved pay. Now you can easily get all the desired CPT information at your fingertips, save time, improve efficiency and keep your practice compliant and profitable.

Supercoder now offers user-friendly and time-saving online tools like Specialty Physician Coder, Code Search and Fast Coder that one can use to access all the new codes to stay compliant and profitable this year. Most of the time, coders find it difficult to search for the right code which are relevant to their practice but this year, Supercoder subscribers can easily find all the CPT code updates with just a click. With a new feature called the “Historical Reference toolbar”, one can easily search for updated CPT codes along with the deleted ones for all specialties.

Also, one can easily view all the information of deleted codes along with 2012 fees and much more with the added advantage of printing this information for future reference. Some of the highlights of the new feature are as follows:

• Look-up 2012 fees, RVUs, and MUEs and get important information from six fee schedules for 2012 fees.
• Read and print detailed new definitions with 2013 E/M Guidelines.
• View and compare all the new and revised codes that will have an impact on your specialty.
• Get information on all the deleted codes and archived news which has been categorized by code set that enables you to view previous code information along with lay terms, CCI edits, allowed modifiers.
• Get access to new and deleted codes for every CPT® 2013 section.

With Supercoder you can easily file accurate claims and stay compliant- thanks to these new and updated features that makes online code look-up easy and convenient.

Doubt over financial viability could be the only thing holding them back.

Home monitoring devices could be the next big thing in health care, but the technology won’t catch on unless doctors get a more lucrative financial incentive for using the technology.

Some HIT products’ selling points focus on providing physicians better rewards, reports blogger Ken Terry. For instance, Watermark Medical offers a home device and a website where for sleep apnea testing. Through a device inserted into a patient’s nose, medical professionals can monitor data from the device’s sensors, and consequently report to a doctor about the patient’s diagnosis.

“The physician charges $250-$450 per test and keeps $100-$150 of that. While the doctor pays Watermark $4,000 for the diagnostic device, it creates a new revenue stream,” Terry writes in his blog. He estimates about 1,000 physicians are using Watermark’s device to do 4,000 tests per month.

GE is not far behind with its Healthymagination — a $6 billion, five-year initiative in which the company has invested about $700 million on R&D, and $250 million in an equity fund for HIT companies. Some of its innovations include portable handheld Vscan ultrasound that will cost 20 percent less than GE’s current bedside ultrasound units, a “low-dose” CT scanner that will cost 15 percent less than current products, and more remote monitoring devices developed in collaboration with GE’s partners.

Many doctors charge on a fee-for-service basis for office visits. Home care service does not appeal to them as much because they either get little or no compensation. For this reason, many doctors turn a blind eye to supporting innovations in home care — even if it’s a lot more economical to monitor patients remotely at home than to have them come for office visits. To get doctors on board, and maximize the potentials, entrepreneurs must offer new types of reimbursement, Terry suggests.

In August 2009, an ABI Research study found that the market for health care monitoring devices was on the verge of explosive growth. The organization predicted that over the next few years the market will show a remarkable 77 percent compound annual growth rate, resulting in global revenue of almost $950 million in 2014.

The Feds are watching… Handle modifier -59 with care. AUDIO: Modifier “-59″ and NCCI Edits.

Respondents fear unresolved reimbursement issues could be a barrier.

The use of telehealth technology will have a positive impact on the health care industry over the next 10 years, a poll by Intel suggests.

Eighty-nine percent of the health care decision makers polled put their bets on the technology, but also expressed some reservations, including the reluctance of patients and caregivers to try it, and the issue of reimbursement.

Telehealth services could be as simple as a physician using email to check on a patient’s condition, or as advanced as two health professionals discussing a case via video conferencing. Respondents believe that the technology will result to better patient care and lower costs. Other benefits mentioned include better doctor access to patient data and early detection of health issues.

Two-thirds of the health professionals surveyed are telehealth users, and 87 percent say they are satisfied with the technology. Non-users say they plan to give it a go with the next year.

“The survey demonstrates the increasing need to shift from the current reactive health care system to a more proactive model that champions the patient and gives clinicians the information they need,” Mariah Scott, director of sales and marketing for the Intel Digital Health Group, said in an Enterprise Networking article.

On the other hand, respondents think that unless the reimbursement process is fully resolved, the issue will continue to hinder the progress of telehealth technology in the industry. For instance, providers and patients may clash over the relative value of telehealth services.

There are also some concerns on the comfort level of patients and providers in using telehealth, although Intel has previously reported a more open perception to using the technology. The study recommends a need for better education to overcome perceived barriers.

The telehealth market is predicted to grow on a much wider scale from 2012 onwards, according to a report by research company InMedica. Mobile phones will play a big role as gateways — reaching as many as 350,000 people in 2014. Last year, health hubs were the most widely used telehealth gateways, constituting about 80 percent of the total gateways market.

The Feds are watching… Handle modifier -59 with care. AUDIO: Modifier “-59″ and NCCI Edits.

HITECH Act requires use of EHRs as tools to inform about disclosures under Privacy Rule.

Health care organizations and providers thought they dodged a bullet long ago when they convinced HHS to exclude disclosures of patient data used in the process of treatment and payments from the HIPAA privacy rules. But now, thanks to the HITECH Act, HHS is back, wondering what would be so terrible about requiring an accounting of such disclosures now.

Through a request for information issued in early May titled HIPAA Privacy Rule Accounting of Disclosures Under the Health Information Technology for Economic and Clinical Health Act (75 Fed Reg 23214 May 3, 2010), the HHS Office for Civil Rights says it expects to learn more about the interests of individuals, and the administrative burden on covered entities as well as business associates, concerning accounting for such disclosures.

Under current standards of the HIPAA Privacy Rule, an individual has the right to receive a listing – known as an accounting of disclosures — that explains when a HIPAA covered entity discloses the individual’s information to others. The current rule, however, does not require a covered entity to list disclosures to carry out treatment, payment, and health care operations.

The HITECH Act of 2009 upgrades the current rule by providing an individual a right to receive information about disclosures made through a covered entity’s use of electronic health records for purposes of carrying out treatment, payment, and health care operations. To do this, the covered entity must have the capacity to track, store and compile a vast amount of information regarding EHRs.

Specifically, the OCR’s RFI seeks comments from health consumers and health care providers/organizations concerning:

• What are the benefits to the individual of an accounting of disclosures made for treatment, payment, and health care operations purposes?
• If you are a covered entity, how do you make clear to individuals their right to receive an accounting of disclosures? How many requests for an accounting have you received from individuals?
• What is the feasibility of an EHR module that is exclusively dedicated to accounting for disclosures (both disclosures that must be tracked for the purpose of accounting under the current HIPAA Privacy Rule and disclosures to carry out treatment, payment, and health care operations)? Would such a module work with covered entities that maintain decentralized EHR systems?

After reviewing comments from the RFI, HHS is expected to issue a Notice of Public Rulemaking on the new accounting for disclosures regulations with a 60-day comment period, according to the law firm McDermott Will & Emery. Final rules will follow thereafter.

There is money to be given out to medical practices for using EMRs. AUDIO: Medical Coding 101: The Need-to-Know for CEOs.

Use this checklist on your next walkthrough to make sure you’re not overlooking crucial security breaches.

It’s always a good idea to complete regular walkthroughs in your health care organization in order to quickly and easily monitor your staff’s HIPAA compliance.

Read on to find a helpful tool for HIT pros in the form of a checklist.

This checklist, created by Patricia Johnston, a consultant with Texas Health Resources in Arlington, TX, can help you catch violations and track problem areas. For each item listed, check if observed or not, the number of occurrences, and add any comments.

• Staff discusses confidential information in public areas.

• Conversations with patient/family regarding confidential information are held in public areas.

• Overhead and intercom announcements include confidential information.

• Phone conversations and dictation are in areas where confidential information can be overheard.

• Visitors in public areas can see computer monitors.

• Unattended computers are not logged out or protected with password-enabled screen savers.

• Computer passwords are shared or posted for unauthorized access.

• Documents, films and other media with confidential patient information are not concealed from public view.

• Whiteboards in public areas have more than the allowable information.

• Medical records are not stored or filed in such a way as to avoid observation by passersby.

• Confidential patient information is called out in the waiting room.

• Confidential information is left on an unattended fax machine in unsecured areas.

• Confidential information is left on an unattended printer in unsecured areas.

• Confidential information is left on an unattended copier in unsecured areas.

• Confidential information is found in trash, recycle bins or unsecured pre-shredding receptacles.

• Patient lists, such as scheduled procedures, are readily visible by patients or visitors.

• Contractors, vendors and other non-patient visitor third parties are not appropriately identified. Staff is not wearing name badges.

• Patient records not filed in locking storage cabinets or rooms that are locked when unattended.

• Security access mechanisms for buildings or departments are bypassed.

• When questioned, staff demonstrate lack of privacy awareness.

Excerpted from Health Information Compliance Alert.

There is money to be given out to medical practices for using EMRs – Don’t let your coding suffer. AUDIO: Medical Coding 101: The Need-to-Know for CEOs.

Pilot program in South Florida enters testing stage.

Voice or speech recognition has been a useful technology for fields including special education, call centers, and national defense. The health care sector could be the next bandwagon passenger, as regulators in Florida are beginning to use voice recognition to combat fraud.

The Florida Agency for Health Care Administration, which administers the state’s Medicaid program, has announced a pilot program launch in July in South Florida that will call patients in Miami-Dade County, and verify — through voice recognition — if they are receiving home health care services, the Miami Herald reports.

The program, dubbed Telephonic Home Health Service Delivery Monitoring and Verification, will store recordings of nurses’ and home health aides’ voices in a software archive. During home visits to Medicare recipients, they will use the patient’s telephone to connect to the automated system, which will then try to match their voice against the one stored on file. The pilot program will last for three years.

AHCA describes South Florida as the national epicenter of Medicare and Medicaid fraud, with medical providers billing the system millions in home health care services that were never provided. Statistics show that somewhere over 75 percent of all health care fraud in the United States emanates from South Florida, according to a post by Miami criminal defense lawyer Samual J. Rabin, Jr. on his web site.

In an interview by 60 Minutes last year, DOJ prosecutor and Medicare Fraud Strike Force leader Kirk Ogrosky pointed out that Medicare fraud is “way bigger than the drug business in Miami,” reports David Malove, a lawyer-blogger. A Florida health agency representative said that over the past three years, an average of 90 percent of Medicaid expenses for home visits came from Miami-Dade County, despite making up only 19 percent of Medicaid recipients.

Common fraud schemes committed by home aides and health care providers include visiting recipients’ homes more times than necessary, billing for visits that never happened, and billing for a visit to a non-qualifying recipient.

There is money to be given out to medical practices for using EMRs. AUDIO: Medical Coding 101: The Need-to-Know for CEOs.