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Relevancy of Narrative Note's Role in Healthcare Increasing
The ongoing debate of whether conventional EMRs are viable solutions to the growing data needs for the future of healthcare delivery systems is escalating now that the ICD-10 implementation is less than 700 days from official use. Increasing from roughly 14,000 codes to over 140,000 codes, ICD-10 implementation poses an interesting conundrum for legacy EMR customers that aren't able to efficiently and effectively capture data for such a vast set of diagnosis codes within their current systems.
Compounding the EMR discussion, Centers for Medicare and Medicaid Services (CMS) is making an aggressive push to reduce fraud and waste in federal healthcare programs. The recent surge in audit activity has raised concerns for both ambulatory and acute care organizations that utilize EMRs in daily practice. Medical documentation that shows a level of sameness between multiple patient visits can be a red flag for audit risk. Unfortunately for clinicians, typical legacy EMR workflows create 'boilerplate' or 'roll-forward' patient notes to the tune of replicating a large portion of the documentation from one visit to the next. In addition to levying heavy fines to practices, CMS auditors looking for this sameness in the documentation are increasingly denying new claims, and have even begun to deny claims retroactively.
What can practices do to navigate these complex issues? The answer may be more simple that previously thought: Narrative Notes.
Clear and comprehensive narrative notes are becoming increasingly vital to both the administrative and clinical sides of a medical practice, but often disappear when a conventional EMR is implemented. Cutting-edge medical documentation technology now allows physicians to dictate patient notes while receiving all the benefits of an electronic health record system, whether a practice has an EMR or not. Narrative notes can overcome EMR shortcomings – boilerplate notes, loss of efficiency, decrease in revenue – while providing the rich data captured by the unique thoughts and actions of a physician at the point of care.
Introducing a narrative note workflow can preserve the rich data desperately needed for quality patient care, mitigating audit and lawsuit risk, and will prepare your practice for the known and unknown future changes in healthcare technology. As the discussion continues, arm yourself with the facts to make an informed decision about the future of your practice.
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Medicare Audits Expanded
Should ambulatory practices worry about their risk? For over a year now, Centers for Medicare and Medicaid Services (CMS) has led an intense pursuit of fraud,  abuse and waste in federal healthcare programs. Recently, the audits have intensified and practices of all types are being targeted for audit. Are you in their crosshairs?
MD-IT's healthcare I.T. consultants have spoken with many practice administrators and physicians about the influx of auditing firms that are popping up to investigate CMS reimbursement claims. Not only are practices seeing an increase of denied claims, but now CMS is looking back through past records searching for evidence of ‘cookie cutter notes’ in order to take back previous payments.
How can your practice mitigate your audit risk? Start with a practice workflow analysis. Next, single out a couple patients you've seen regularly over the past year and compare the patient notes. Look for evidence of roll-forwards, copying/pasting, or boilerplate text. If you notice a lot of similarity between the separate visits, you are at risk and should immediately take measures to prevent further damage.
Learn more about ways to mitigate your audit risk with MD-IT!
2011 ePrescribe Reminder
If you haven’t yet participated in the Medicare Electronic Prescribing (eRx) Incentive Program, you have 60 days to write at least 25 ePrescriptions to meet the 2011 reporting period deadlin e.
If you miss the December 31, 2011 deadline, you will incur a 1.0% penalty for 2012 and a 1.5% penalty for 2013.
However, if you write at least 25 ePrescriptions by the end of 2011, you can avoid the 2012 and 2013 penalties and earn a bonus of 1.0% for 2011.
Note: Schedule drugs are not eligible as unique ePrescription events and do not count in the reporting activity of this program.
Check out our Medicare Electronic Prescribing Incentive Program Frequently Asked Questions page.
Founded in 2000, MD-IT is a leading provider of medical documentation software and service.
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EMR Optimization Saves $30,000
St. Peters Bone & Joint Surgery (SPBJ), an orthopedic practice based in St. Peters, Missouri, realized an annual savings of $30,000 by optimizing their Sage electronic health record system with EMR Optimization software and service from MD-IT. By re-introducing dictation via the MD-IT iConnect for iPhone into the practice workflow, SPBJ was able to devote more time to patient care and reduce the potential for errors in their clinical documentation.
MD-IT developed an EMR Optimization plan for SPBJ, enabling the practice to utilize the speed and accuracy of dictation combined with all of the benefits of the native Sage system. In addition to the financial savings, the practice has reduced delay between patient visits and completed chart notes, and it has significantly reduced the amount of manual copy/paste that physicians and staff had to endure. Instead of 45 hours a week spent moving, fixing and correcting documents, a single staffer is spending less than two hours per week.
Read the SPBJ Case Study
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