Documentation holds special significance in clinical care – care coordination, easy reference, clinical research, and clinical certification are all made possible by well-documented clinical encounters. But documentation got a new dimension when fee-for-service was first replaced by Medicare-supported reimbursements. And, with the gradual inclusion of private players in health insurance, the significant of documentation is felt operationally too – documentation is the single-most source for billing, coding, and verifying the accuracy of claim submission.
Over the years, there has been considerable increase in both incidence and volume of documentation – increase in insurance-backed patients has largely been responsible for this. As a result, staff’s documentation responsibilities too have gone up. What used to a few demographic entries, insurance eligibility verifications, charge entries, billing, coding, submission and follow ups, has suddenly assumed gigantic proportions. And, when internal staff is forced to manage beyond their capacity, issues such as delay, denial, resubmission, audit, and arbitration are bound to be common. The fact that physicians find themselves in multi-payer system – which continues to be tougher by the day – is reason enough to practice accurate documentation so as to be operationally viable.
EHR provides the right platform needed to respond with operational documentation as required by your payers. As an EHR is capable of integrating clinical documentation with Practice Management System (PMS), billing and coding errors will be more unlikely. Further, with the capacity for large data base, EHR can be relied upon for any future reference or audit verification from payer side. Significantly, EHR is supposed to be a primary requirement for ensuring patients’ privacy and security as mandated by HIPAA 5010.
EHR-enabled documentation will be more than just a requirement as practices continue to negotiate economic uncertainty, declining reimbursements, healthcare reform and an increasing emphasis on performance improvement. While the imminent ICD-10 regime promises streamlined billing practices, physicians will have to do whatever best they can to have a documentation system that is consistent, comprehensive, and accurate enough to be translated into ICD-10 compliant billing and coding. Practices that lack the will and resources to adopt progressive EHR-enabled documentation may well lose considerable chunk of…