I’m Dr. Hassan, a Board-Certified Physiatrist and Independent Practice Owner. I help physiatrists start and grow their own profitable practices so they can achieve financial independence and live without limits.
An electronic medical record (EMR) is like the digital version of a patient’s chart. EMRs contain patients’ medical and treatment history from one particular practice. Because electronic medical records reduce errors and improve the quality of care, the federal government has mandated its use.
Many physicians, however, perceive EMRs to be overly complicated and unnecessary in providing quality care. As a result of their reluctance, they’re missing out on the EMR’s ability to increase workflow efficiency. Not only does your EMR assist your practice in becoming more HIPAA compliant, but it can also simplify your billing and claims processes.
Your EMR can be one of the most excellent tools in helping you to optimize your billing.
Each EMR has systems and templates in place to help you perform your job efficiently. They also provide you access to support teams that can answer questions on topics you seek clarity. They can be streamlined and set up to document your patient encounter concisely and succinctly.
Having a good understanding of E and M codes and/or CPT codes allows you to leverage the internal systems of your EMR. to maximize charge capture while insulating yourself from costly audits. Matching up your coding profile with Medicare benchmarks, for instance, can give you the insight into coding trends you might not be aware of. In doing so, not only will you reduce your audit risk, but your bottom line may also be rewarded. [Learn more ways to increase your bottom line by reading my blog post on minimizing overhead costs.]
Knowing the requirements and required elements needed to build at each level or procedure code affords you the ability to create templates that satisfy these requirements, while accurately documenting the complexity of the patient’s visit. Your EMR allows you to capture the burden of care, thought process, clinical knowledge, knowledge synthesis, and application of all these factors to create the most accurate depiction of the visit. Being able to document the full complexity, skill, and effort thoroughly it takes to care for patients helps justify billing of complex encounters.
Beyond hardware and software, the total cost of your EMR solution includes clinical and staff training time and clinical and IT support. Take advantage of this support. Sit down with the billing and coding specialist in your practice or hospital to discuss the required elements for each visit level. Then, reach out to the educator for your particular EMR platform to help you create high-quality, high-yield templates. These templates will help you to depict the complexity of your patient encounters accurately.
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I’m Dr. Hassan, a Board-Certified Physiatrist and Independent Practice Owner. I help physiatrists start and grow their own profitable practices so they can achieve financial independence and live without limits. Follow me on social media @DrHassanRehab.
