EMRs and The Physical Exam

By Steve Adams


With an increasing number of providers continuing the transition to electronic medical records (EMR), it is important to review one component of evaluation and management (E/M) coding that is often overlooked when creating your EMR templates.

The federal government, in conjunction with the American Medical Association (AMA) has developed two sets of physical exam guidelines that providers must adhere to when documenting and selecting any set of E/M codes.

Whether you select to document with the “1995” exam guidelines, or “1997 - bullet” exam guidelines is up to you. However, most providers are unaware of the difference in these two guidelines and if you don’t specify which set you want to use with your EMR, you are setting yourself up for disaster if ever audited.

Let’s now take a look at the two sets of guidelines so you will be able to make a decision on which one of the two sets of guidelines you want to use to help ensure documentation compliance.

1995 Guidelines: This is a set of body areas and organ systems that when used in conjunction with each other allows you to document and select any number of E/M codes. The only compliance issue that we see with the 1995 exam happens when a provider selects E/M services that require a “comprehensive 8-organ system exam.” The AMA and CMS specify that a comprehensive exam be made up of only organ systems and not a combination of organ systems and body areas. The following are the ONLY recognized organ systems from CMS and the AMA. If you document a comprehensive exam and any of your headings are different from these key organ systems, you’d need to contact your EMR provider and change the headings:

The 12 organ systems: Constitutional, Eyes, ENMT, Lymphatic, Cardiovascular, Respiratory, Gastrointestinal, Genitourinary, Musculoskeletal, Neurological, Psychiatric, Skin

Now, once you get the headings correct, you can document whatever findings you want regarding the system(s) being examined. In fact, CMS writes that a notation of “normal” is acceptable.

1997 Guidelines were then developed as an option for providers not wanting to document exams of organ systems, but to be able to document findings from a combination of systems and areas. However, the federal government is very specific about the areas and systems you examine AND what you are able to document regarding your findings within those systems and areas. In other words, it’s not sufficient to select an exam of the Abdomen, under the 1997 guidelines, and document whatever you want regarding your exam findings. Specifically, for an abdominal exam the government will give you “credit” if you document your exam and findings pertaining to the any of the following five elements:

Abdomen

• Examination of abdomen with notation of presence of masses or tenderness

• Examination of liver and spleen

• Examination for presence or absence of hernia

• Examination of anus, perineum and rectum, including sphincter tone, presence of hemorrhoids, rectal masses

• Obtain stool sample for occult blood test when indicated

Different E/M codes require a different number of “elements” be documented for each E/M code.

For an example Multi-System Examination Color Code-it Form, click HERE.

If you believe you are set up to document the 1997 guidelines, but you weren’t informed of the only findings you could document for proper “credit,” you’re documentation might not be as compliant as you think.

The point is, unless you are familiar with the specific set of examination guidelines you are using (1995 vs. 1997), the use of an EMR for documentation compliance could be a fruitless endeavor.

What to do?

1. Contact your EMR vendor to ensure they are familiar with the difference in the 1995 and 1997 guidelines as they pertain to the physical examination.

2. Ask them to let you know which system you are currently using for your template.

3. Do some research on your own. The following is a link to the CMS Documentation Guidelines for Evaluation and Management Services: http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/EMDOC.html

4. Consider having an outside review of some of your new and established patient notes to ensure you have had your templates set up appropriately. Normally after a review of 5 new and 5 established physical examinations an auditor can offer you suggestions on your documentation compliance.

Please don’t overlook this very important component of your EMR documentation compliance.

Steve Adams is a Certified Professional Coder and Senior Consultant with InGauge Healthcare Solutions. Contact Steve for consulting or educational programs at steve.adams@inguagehsi.com. To read more articles like this and to register for practice management tele-classes, visit http://www.efficiencyinpractice.com/

This article can be reprinted freely online, as long as the entire article and this resource box are included.

Your Patients Need Sleep Help!

by Duane M. Johnson, PhD

Sleep is vital to our health and well being. Over 100 million people of all ages in the US regularly fail to get a good night’s sleep. Many of these are your patients. Sleep deprivation is serious because it results in decreased daily performance, dramatically increased safety risks and dangers, and personal and business relationships suffering due to mood disturbances and exacerbated health complications.

Over 80 different sleep disorders have been identified via clinical studies. Sleep disorders impact cardiovascular health, diabetic maintenance, pregnancy outcomes, child development, surgical success, and other life altering and threatening matters.


The first priority is you. As a health professional, are you managing your own sleep needs so you are benefitting from healthy sleep? How are your family members doing?

For your patients, do you include a sleep screening during your patient H&P exam? A significant amount of your patients have sleep health problems that need attention. If evaluated and treated, the results combine to make your family, OBGYN, cardiology and most other specialty treatment outcome even more probable and successful.

A number of doctors and physician extenders have inserted the STOP sleep screen into their health intake form or verbal evaluation. These fours questions quickly bring patient sleep issues to your attention.

• Snoring – Do you snore loudly?

• Tired - Do you often feel tired, fatigued or sleep during the daytime?

• Observed – Has anyone observed you stop breathing during your sleep?

• Pressure (BP) – Do you have or are you being treated for high blood pressure?

The most common sleep issues are snoring, sleep apnea, restless legs, insomnia and simply poor sleep hygiene knowledge. When treated, many patients have noticeable improvement in their daily performance, safety, and relationships which also often contribute to solving their presenting problem.


The STOP questions, when used with four more questions now called the STOP-BANG questions, will dramatically improve your quick sleep diagnostics evaluation.

• BMI - BMI more than 30?

• Age - Age over 50 yr old?

• Neck - Neck circumference greater than 15” (women) 17” (men)?

• Gender - Male?



With convenient home sleep studies, proactive computer program sleep awareness education, cognitive behavioral therapy, CPAP and sleep oral appliance, and other sleep health services now available, your practice can orchestrate patient sleep service help that at times dramatically turns patient lives around. These sleep services, in cooperation with a sleep professional either provided internally through your practice or in referral collaboration with sleep professionals at their sleep center, can ethically and legally add a new revenue stream for your practice.


Make it a professional goal to learn more about how to integrate a patient sleep screening and treatment service into your clinic or practice. For example, a snoring service is an excellent starting point since it is estimated by the American Academy of Otolaryngology – Head and Neck Surgery that 25% of the U.S. population are habitual snorers.

Based on my many years of consultative practice experiences, I can assure you that treated sleep patients are so grateful they frequently will spontaneously hug you for their positive life changes, even their marriages you saved.

Oh, by the way, you will also be pleased with the enhanced financial improvements it brings your practice’s bottom line.
For further helpful information contact:
Duane M. Johnson, PhD
Sleep Center Management Institute
http://www.sleepcmi.com/
djohnson@sleepcmi.com
1-888-556-2203


Duane Johnson, PhD is the Senior Partner and co-founder of Sleep Center Management Institute and a contributing author to Efficiency in Practice. For more articles like this and our free report, Patient Collections – It’s Make or Break for Many Practices, visit http://www.efficiencyinpractice.com/

This article can be reprinted freely online, as long as the entire article and this resource box are included.

How does your practice function when your technology is lost?

By Brian L Tuttle, CPHIT, CHP, CHA
If you are familiar with the psychologist Abraham Maslow, and his famous “hierarchy of needs”, then you will know he clearly was not born in the age of the internet. According to Maslow, “needs” are listed in order of importance beginning with essentials like: food, water, safety, security, love, prestige and ending with the elusive self-actualization. However, in today’s modern age it seems the list should go like this: INTERNET, CELL PHONE, food, water, safety, security, love, prestige and self-actualization.

This of course is a little bit of jest but have you considered what your practice would do if you lost your technology? Do you have a plan for just a day or two of downtime? What about a long term plan? Does your practice have any Contingency Plan at all?

In performing over 200 HIPAA audits, I have noticed an alarming trend; most practices do not have a Contingency Plan in place at all! Did you know that this is a required standard of the HIPAA security rule as stated in citation 164.308(a)(7)(i), and failure to do so could result in fines, or worse, the total loss of your practice in the event of a disaster?

In this article, we are going to focus on the minor disaster. Minor disasters happen much more frequently – for example, the loss of access to technology. What would you do?

The first thing you need to do is isolate the problem. What caused the outage? Is it the internet service provider? Obviously this will bring down any web based EMR. Is it the server that houses your EMR onsite? Do you have a contact list of entities to call – IT vendor, EMR vendor, internet service provider, etc?

Tip: When calling IT provider or EMR support be sure to mention you are “completely down” as this usually will expedite the process. Remember the adage “the squeaky wheel always gets greased first.”

You should have a plan in place that allows you to function and continue to see patients when no technology is available. On the clinical side you can revert to paper for charge capturing, patient visit recording, prescriptions, etc. Do you have these items handy? (i.e. super-bills, prescription pads, etc.)?

What about patient histories? The move to an “all electronic” world means these charts may not even exist at your practice anymore. In some cases, it is possible to access the server (assuming it is onsite) using a very powerful UPS (uninterrupted power supply) which can power the server and a printer. This would give you the ability to print from within your practice management system in a pinch. Tip: An entry level UPS should last about 30 minutes. However, the time can vary, depending on the load of the server.

One other suggestion would be to keep a copy of the EMR and patient database on a local laptop. This would allow you to access patient records on a machine with a long battery life. Even in a complete power outage, you could gain emergency access to patient data.

What if your internet is down for a few days and your EMR is housed on the web?

One thing to consider would be to use an “air card.” Most cell phone vendors offer these at reasonable prices. In some cases, a cell phone with internet access can even be used as an “ad-hoc” modem plugged into PC to get you online. Also in some cases, the cell phone itself can be used to access the internet and therefore the EMR.

Another thing to consider is getting a backup internet line. Example: if you currently use a T1 to access the internet, purchase a cheap DSL or cable line as a backup.

The bottom line is you need to have a contingency plan in place for minor events as well as major catastrophes. Not only is it a requirement per the HIPAA Security Rule but it is also a wise business decision.

How do you develop a Contingency Plan for your practice? To start, download this template to create your plan.
For more information, please contact: brian.tuttle@ingaugehsi.com

Brian Tuttle is a Certified Professional in Health IT (CPHIT), Certified HIPAA Professional (CHP), Certified HIPAA Auditor (CHA), and Certified Business Resilience Auditor (CBRA) with over 13 years experience in Health IT and Compliance Consulting. For more articles like this and to download your free report, Patient Collections – It’s Make or Break for Many Practices, visit http://www.efficiencyinpractice.com/ and sign up for your complimentary subscription to Efficiency in Practice.

The Importance of A Referring Physician

by Annie Mathies

It is often forgotten how important a referring physician really is to a practice. Referring physicians keep specialists in business. It is not just private practice physicians that need to focus on building and maintaining these relationships, physicians employed by hospitals also need to focus on this issue.


You often hear physicians say “I don’t need to worry about referring physicians” or “I have been getting patients from these physicians for X number of years”. The physicians forget that things happen and referrers may change their referral patterns. Some situations that could change or influence a physician’s referral pattern are:

• The referring physician may become employed by a hospital or merge with another group; when this happens the referring physician may be forced to change where they send their patients.

• The referring physician or his staff may have issues/concerns with the specialist’s staff. (i.e. - problems getting the front desk to answer the phone or relay messages, a rude staff, or a staff that will not accommodate new patients).

• A new physician came to the area and is building relationships/networking/using new techniques.

• A history of poor communication with the referring physician about patients care.


Specialists need to be thinking - How do I keep these physicians happy and keep the business coming? In doing so they should focus on:

• Making sure the referring physician has a seamless way to interact with the physician office.

• Always communicating what is going on with their patient to the referring physician or their office. It could be a phone call, letter, email, etc. AND, make sure to thank the physician for the referral.

• If the specialist is using a new technique or service, it needs to be marketed directly to the referring physicians:

*Put the information on your website, blog, Facebook page.

*Hold a reception for the local physicians to keep them informed. It could be a simple as a wine and cheese event.

*Send out a mass mailing/email. If you are reaching out to new referring physicians in this letter, make sure to introduce the services that separate you from the competition.

*Notify the PR department in hospitals where you work.

• Have a secret shopper call your staff and make sure that they are handling a referring physician in the appropriate manner.

It just takes a few extra steps to keep a referring physician happy and sending patients. It is well worth the effort.



Annie Mathies is an experienced medical practice administrator and a contributing author to Efficiency in Practice. She currently consults with medical groups, surgical centers and hospitals on mergers, acquisitions, office work flow and basic practice management and can be reached at anniemathies2@comcast.net .


To read more articles like this, visit http://www.efficiencyinpractice.com/ and subscribe free of charge. This article can be reprinted freely online, as long as the entire article and this resource box are included.

Can you bill an E&M service without seeing the patient?

by Steve Adams, CMS, CPC, CPC-H, CPC-I, PCS, FCS, COA

Have you ever wondered if you could bill for an evaluation and management (E&M) service or a diagnostic test without actually providing an “in person” visit with the patient?

For example, a patient in pre-term labor is seen in the Emergency Room (ER). The ER physician contacts you and you ask them to place the patient in observation on your service. You receive a telephone call from labor and delivery (LD) later that day or night to inform you of the status of the patient. You request a fetal non-stress be performed and other specific test(s) and when complete the results are telephoned back to you at your home or office. A few hours later you discharge the patient to home and request she follow-up with you in the office tomorrow.

Now, you’ve provided a “medical service” and received information on “diagnostic tests” but in this example the E&M services was not provided in conjunction with an “in person” face-to-face encounter with the patient and you didn’t have “direct visualization” of the NST - so in fact, neither service is billable.

According to CMS IOM 100-02 chapter 15:

A service may be considered to be a physician’s service where the physician either examines the patient in person or is able to visualize some aspect of the patient’s condition without the interposition of a third person’s judgment. Direct visualization would be possible by means of x-rays, electrocardiogram and electroencephalogram tapes, tissue samples, etc.

For example, the interpretation by a physician of an actual electrocardiogram or electroencephalogram reading that has been transmitted via telephone (i.e., electronically rather than by means of a verbal description) is a covered service.

To have a billable E&M service you would have to go to the hospital and see the patient “in person.” To bill for the NST or any other imaging test, they would have to be provided to you in an electronic format, prior to interpretation, and not by means of a verbal description.

Remember, with very few exceptions (care plan oversight, home health certification and recertifications, certain telemedicine services, etc), if you don’t provide an “in person” service or a “direct visualization” of a diagnostic test you are not permitted to bill for your professional services.

Practical and Achievable Approaches to Compliance - Tips for Preventing Coding/Billing Audits, and What to Do If You Get Audited

Join us for this Informative Tele-class

Thursday, March 15, 2012

12:00 pm (EST)

There are easy steps any medical practice can take to reduce their exposure to coding audits by Medicare, Medicaid and other payers. You don’t necessarily have to implement a costly and time-consuming, full-blown compliance program to start audit proofing your medical practice.

Clearly it is best to avoid audits in the first place. But sometimes – despite your best efforts – they happen and you have to prepare an effective audit response. We’ll cover those responses, as well.


Topics will include:

* Common Types of Audits Impacting Medical Practices.

* Audit Horror Stories . . . . . and . . . . . Audit Success Stories.

*Which Audits Are Really Dangerous

*Update on RAC Audits.

*Medicare Carrier/MAC’s New Partner – ZPICs.

*Common Audit Targets.

*Responding to an Audit.

*Practical/Achievable Approaches to Compliance and Audit Prevention.

*Self Audits to Reduce Compliance Risks.

*Voluntary Refunds. Whistle-Blowers. And Much More.

REGISTER NOW

presented by

InHealth Consulting & Educational Services

and

Guest Expert Hoyt Torras,

Senior Consultant, InGauge Healthcare Solutions

Mr. Torras' nearly 40 years experience provides expertise in General Practice/Group Practice Management and Administration, Reimbursement, Coding, Regulatory Compliance, Financial Analysis & Projections, and Managed Care Contracting.

He presents seminars and educational programs, as well as develops medical publications and training manuals.

Register for this tele-class HERE

The Efficiency in Practice Manager Association Membership includes monthly tele-classes like this, recordings of past tele-classes, a members-only forum, and discounts on products and services. Click HERE for more information and to JOIN



Five Tips for Helping Patients Pay off a Balance

by Michelle Dunn

Medical bills aren’t always like other bills, many times they are not planned for and the bill is an unexpected surprise that some people cannot afford. If a patient doesn’t have insurance, this can be a real problem, especially in this economy where as more and more people lose their jobs they also lose their medical insurance.

As a doctor billing patients when they cannot pay in full at the time of service, you must have policies and procedures in place for your office staff to follow in order to successfully get paid for your services. You should look at it as part of your job to help your patients be able to pay your office.

With that in mind here are my top five tips for helping your patients pay off a balance due.

1. Be realistic when talking with patients about payments. If you aren’t realistic, you won’t get paid. Ask them about their income and monthly bills and set a monthly payment they can realistically make, otherwise they won’t make any payment.

2. Get payments twice a month rather than once a month. Even if the installment payment is less, if someone is paying twice a month it could be more than one monthly payment, resulting in the bill getting paid quicker.

3. Put it in writing. Whatever you decide with your patient in regards to their bill, put it in writing and send them a copy.

4. Follow up. Any collection efforts you put in go down the drain if you don’t follow up.

5. Offer your patients a couple of solutions. Many people are embarrassed to have a past due balance with you, and want to pay it off as quickly as possible. Offer them a couple of options so they can be part of the decision making process on how they will pay you.




Michelle Dunn, author of The Guide to Getting Paid, is an expert on the topics of credit and collections. For more information on Michelle, visit http://www.credit-and-collections.com/. To read more articles like this, visit http://www.efficiencyinpractice.com/ and sign up for a complimentary subscription to our Efficiency in Practice enewsletter.

This article can be reprinted freely online, as long as the entire article and this resource box are included.