EHR Record Keeping Principles

Questions and Answers

What is essential to document in order to provide services and ensure payment?

Insurance information

Historical treatments

Patient demographics

Medical necessity (correct)

What is the purpose of using S codes in coding?

To increase complexity of billing

To replace CPT codes entirely

To provide a lower fee for routine eye exams (correct)

To document complex procedures

S Codes are categorized under which coding system?

Healthcare Common Procedure Coding System (HCPCS) (correct)

Current Procedural Terminology (CPT)

National Drug Code (NDC)

International Classification of Diseases (ICD)

What should be noted about the Medical Decision Making (MDM) for different patient ages?

It varies significantly based on the patient's condition. Signup and view all the answers

What aspect is crucial to ensure proper chart documentation?

Compliance with state regulations Signup and view all the answers

Which of the following best describes the role of Medical Necessity in healthcare?

A standard for billing and payment of services Signup and view all the answers

What should be done when amending a signed chart after the date of service?

Identify it as an amendment and sign and date it Signup and view all the answers

How should corrections or amendments be indicated in medical records?

Clearly and permanently identifying each modification Signup and view all the answers

What is required for delayed entries in a medical record?

Sign and date the entry upon recording it Signup and view all the answers

What function does a single strike line serve in paper records?

It allows original content to remain readable Signup and view all the answers

Which insurance provider hypothetically reimbursed the highest amount for the 92004 procedure in the example given?

Aetna Signup and view all the answers

What could happen if the fee set by a practice exceeds the allowable amount for a procedure?

The fee will be adjusted down with a specific denial code. Signup and view all the answers

Why should practices avoid setting their fees too high?

Patients might avoid the practice due to expense. Signup and view all the answers

If a practice sets its fee at $250 for an exam, what might patients experience when receiving their benefits summary?

Patients may express anger over high billing charges. Signup and view all the answers

Why is it important to charge all patients the same fee for a given code?

To meet regulatory compliance and fairness. Signup and view all the answers

Study Notes

Electronic Health Records (EHR) and Documentation

Maintaining accuracy in electronic record-keeping is critical for document submission to various auditors and committees.
Amendments or corrections in records must distinctly identify changes, including the original content, modified content, and accompanying dates and authorship.

Claim Submission and CPT Coding

Claim submissions require precise documentation of patient demographic and insurance information, as well as accurate coding.
Use the most comprehensive ICD-10 codes available, such as H25.813 for various cataract forms.
Employ CPT procedure codes for all medical care, utilizing HCPCS S-codes only when accepted by vision plans.
Claims should be straightforward, focusing on clarity and conciseness.
Ensure diagnosis codes support the medical necessity of procedure codes.

ICD-10 Coding Guidelines

Coding standardizes the identification of items and procedures provided to patients.
Accurate coding is essential for insurance reimbursement; procedures should be linked to corresponding ICD-10 diagnosis codes.
Key rules include coding for the patient's current condition and assigning codes at the highest level of specificity.
Chronic conditions must be coded whenever applicable, while conditions not present during the visit should not be coded.

Medical Necessity in Documentation

Medical necessity is essential for coverage and requires clear documentation in patient records.
Testing and procedures documented in charts should be medically justified. For example, certain diagnoses like H40.013 support specific testing that aligns with medical necessity.

HCPCS S-Codes

S-codes represent routine eye exams and lower complexity services, indicating that medical necessity may not have been established.
Care provided under S-codes is still subject to state board standards and can differ from more complex CPT codes in terms of medical decision-making.
Understanding differences between S-codes and CPT codes is crucial, as routine services are not equivalent to complex care, even if similar procedures are performed.

Medical Complaints

Common issues include dry eyes, scratchy eyes, eye pain, watery eyes, and loss of vision.
Additional complaints may involve distorted vision, drooping eyelids, floaters, flashes, photophobia, and asthenopia.
Many patients may not realize their eye conditions are eligible for insurance coverage.

Importance of Medical Documentation

Essential for recording health history, including past and present illnesses.
Chronicles care to ensure quality healthcare delivery over time.
Facilitates communication among healthcare professionals for ongoing patient care.
Aids in accurate claims review and payment processes.
Supports utilization review and quality care evaluations, and data collection for research.

Comprehensive Patient History

Use a detailed medical history questionnaire for patients to capture their chief complaints efficiently.
Reference initial history forms at subsequent visits, refreshing every three years or upon significant health changes.
Some practices offer downloadable medical history forms from their websites.

Establishing a Chief Complaint

A chief complaint summarizes the patient's primary issue in their own words, guiding examination and billing.
Defined similarly by AMA and CMS as a concise description of the reason for the patient encounter.
Accurate documentation of the chief complaint is crucial for determining the appropriate examination type.

Amending Signed Charts

Providers should document all relevant entries at the time of service, though amendments may be necessary later.
Amendments must be clearly marked, signed, and dated without deleting original entries.
Paper records can use a single strike-through for changes, maintaining visibility of original content.
Electronic Health Records (EHR) must effectively show both original and modified content, with clear authorship and date stamps.

Principles of Document Correction

Corrections should be permanently identifiable as amendments or delayed entries.
Must indicate the date and author of changes while retaining original content.
Ensures accountability and integrity of the medical record throughout patient care.

Medicare Provider Types

Normal optometry offices do not operate in Medicare facilities; use non-facility fee for reimbursement research.
Choosing to accept Medicare allows acceptance of their fee schedule as full payment, qualifying as a “Medicare Participating Provider.”
Non-Participating Providers can accept Medicare patients without agreeing to the fee schedule, receiving 95% of the Participating Provider rate.

Limiting Charge

The Limiting Charge is the maximum a Non-Participating Provider can bill Medicare patients.
It is set at 15% above what Medicare approves for Participating Providers, protecting patients from excessive charges for covered services.

Provider Comparison

Doctor A (Participating Provider) receives 136.47fora92004service:Medicarepays136.47 for a 92004 service: Medicare pays 136.47fora92004service:Medicarepays109.18, patient or supplement pays $27.29.
Doctor B (Non-Participating Provider) receives a lower reimbursement of 129.65;Medicarepays129.65; Medicare pays 129.65;Medicarepays103.72, patient pays 25.93plusa25.93 plus a 25.93plusa19.45 extra charge, leading to a potential total of $149.10.

Advantages and Disadvantages

Non-Participating Providers can receive higher reimbursements but face administrative burdens and explain additional fees to patients.
Private or self-pay patients save time and resources by avoiding claims processing; prompt-pay discounts of up to 20% can be offered.

Insurance Agreements

Agreeing to an insurance plan means accepting its payment rates and fee schedule.
Understanding different insurance reimbursement rates is crucial for business viability, including researching regularly.

Medicare Administrative Contractors (MACs)

Twelve regional MACs handle Medicare claims, each with its own fee schedules based on location.
Federal CMS Physician Fee Schedule look-up tool is useful for researching reimbursement rates by CPT code across various regions.

Setting Fees

Setting fees requires analyzing practice overhead, financial demographics, and desired patient load to maintain profitability.
All patients should be charged the same "usual and customary fee” per CPT code, regardless of insurance.
A balance must be found so fees are not excessively high or low; overly high fees may deter patients and create client dissatisfaction.

Fee Examples

Hypothetical reimbursements for a 92004 (comprehensive ophthalmological evaluation) show various payer amounts:
- Aetna: $131.17
- BC/BS: $129.20
- Cigna: $102.81
- Humana: $97.74
- Medicare: $114.35
- United Healthcare: $77.46
Setting fees too high can lead to dissatisfaction as patients are likely to question perceived overcharging when reviewing EOBs.

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Description

Explore the essential principles of medical record keeping within Electronic Health Records (EHR). This quiz covers the necessary considerations for document submission to various auditing bodies and how to handle amendments, corrections, and delayed entries. Test your knowledge on the key requirements for compliant and effective EHR management.