Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CIMC, AAPC ICD-10...

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Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CIMC,

AAPC ICD-10 Proficient

Disclaimer

This presentation was designed solely for educational purposes. Use of this information is prohibited by anyone other than the intended recipients without express written permission of Rizhink Medical Consulting, LLC.

The information was current at the time of publication, however payer policies frequently change thus it is ultimately the responsibility of the provider to verify information.

Rizhink Medical Consulting, LLC made reasonable efforts to ensure the accuracy of the information contained herein, however makes no guarantee that this information is error-free and is not liable or responsible for the outcomes or consequences as a result of using this information.

CPT only © 2014 American Medical Association All Rights Reserved

All Rights Reserved Rizhink Medical Consulting, LLC 2

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What is an EHR?

An EHR Is:

• Electronic Health Record

• Electronic version of medical history

• Includes key administrative clinical data

• Automates access to information


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What is an EHR?

An EHR Does:

• Streamline the physician’s workflow

• Support care-related activities

• Improve patient care

• Improve accuracy and clarity of medical records


What is an EHR?

EHR Perks:

• Copy, paste and pull forward features

• Visit templates

• E/M Coding tools

• Integrated diagnosis codes


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What is an EHR?

EHR Pitfalls:

• Copy, paste and pull forward features

• Visit templates

• E/M Coding tools

• Integrated diagnosis codes



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Image courtesy of http://www.greenwayhealth.com/solutions/primesuite/ehr-pm-web-demo/


Image courtesy of http://gunston.gmu.edu/healthscience/722/OnlineMedicalRecord.asp


http://www.greenwayhealth.com/solutions/primesuite/ehr-pm-web-demo/







http://gunston.gmu.edu/healthscience/722/OnlineMedicalRecord.asp

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Image courtesy of http://www.ehrmarket.com/blog/wpcontent/uploads/NextGen_mainview_large.jpg


Image courtesy of http://www.ehrmarket.com/blog/wpcontent/uploads/NextGen_mainview_large.jpg


http://www.ehrmarket.com/blog/wpcontent/uploads/NextGen_mainview_large.jpg






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Image courtesy of http://www.versasuite.com/~versa/specialties/161.html




http://www.versasuite.com/~versa/specialties/161.html

http://www.versasuite.com/~versa/specialties/161.html








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Images courtesy of http://www.greenwayhealth.com/solutions/primesuite/ehr-pm-web-demo/


Image courtesy of http://www.comchart.com/images/screenshots/pgn2sample.jpg










http://www.comchart.com/images/screenshots/pgn2sample.jpg

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Images courtesy of http://www.comchart.com/images/screenshots/pgn2sample.jpg


Image courtesy of http://www.medicaldatamanagementgroup.com/micromd-electronic-medical-records-em-coding/


http://www.comchart.com/images/screenshots/pgn2sample.jpg

http://www.medicaldatamanagementgroup.com/micromd-electronic-medical-records-em-coding/












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Image courtesy of http://www.setma.com/epm-tools/tutorial-e-and-m-codes




http://www.setma.com/epm-tools/tutorial-e-and-m-codes



















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What is Auditing?

General Definition: “A planned and documented activity performed by qualified personnel to determine by investigation, examination, or evaluation of objective evidence, the adequacy and compliance with established procedures, or applicable documents, and the effectiveness of implementation.”

Definition from Wikipedia


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What is Auditing?

E/M Auditing:

• Level of service met

• Signatures present

• Orders present

• Documentation guidelines adhered to


What is Auditing?

Why Audit E/M Services:

• Compliance

• Decrease risk

• Cert

• RAC

• OIG


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http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/Downloads/November2013ReportPeriodAppendixFinal12-13-2013_508Compliance_Approved12-27-13.pdf


https://oig.hhs.gov/reports-and-publications/archives/workplan/2014/Work-Plan-2014.pdf


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Auditing in the EHR

The History:

• Is a CC present?

• Who documented the CC?

• Who documented the HPI?

• How was ROS collected?

• Was PFSH reviewed? Updated?


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Auditing in the EHR


Auditing in the EHR


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Auditing in the EHR

The Exam:

• Must be performed and documented by the physician

• Be cautious of pre-populated exam

templates

• Only document what’s actually

examined


Auditing in the EHR


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Auditing in the EHR


Auditing in the EHR

The Assessment & Plan:

• Diagnoses included must be supported in the note

• Be cautious of problem lists used as assessments

• Be cautious of integrated diagnosis codes

• Watch for physicians’ “favorites list”


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Auditing in the EHR



Auditing in the EHR

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Auditing in the EHR


Auditing in the EHR

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What Should Your EHR Do For You?

• Simplify documentation processes while increasing the quality of document

• Ensure guidelines are met

• Decrease risk


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What Should Your EHR Do For You?


• Signatures within each area of the medical record

• Indication that PFSH and/or ROS was reviewed

• Templates promote easy documentation without causing cloned look

• Encourage proper coding


Questions?

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Contact Information

Ellen Risotti–Hinkle President & CEO

Rizhink Medical Consulting, LLC

(317) 431-8307 [email protected]

www.rizhink.com

mailto:[email protected]

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Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CIMC, AAPC ICD-10...

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