We asked our expert coders:

“What is the #1 thing that can be done immediately to increase reimbursements?”

You may be surprised by the answer: 

Improve Documentation.

Your clinical documentation is the key to your reimbursements and the profitability of your practice. The simple answer to how you can make sure you are maximizing reimbursements for your practice is by improving your clinical documentation and detailing every surgical dictation… the end result can literally take your coding to the next level.

Detailed documentation is imperative.

You know what procedures you performed but remember, you can only get paid for what your notes say you performed. Documentation, such as the operative report and op notes are the only way a coder can translate the procedures performed into billable revenue via (CPT codes). Incomplete or vague documentation can lead to a major loss in billable revenue. By making sure you include the 4 following details in every dictation, Coders can determine the correct level codes are claimed so that you are reimbursed adequately.

Your time matters – Make sure to state the amount of time spent with the patient in the plan portion of the dictation. For example, “I’ve spent __ minutes face-to-face with the patient.” Having that time included could bump your visit code to the next level.

Classify treatment plans – State clearly if a fracture is seen and being treated either conservatively or surgically. This cuts down on addendum’s and corrected claims and helps get paid faster.

Detailed Dictations – State chief complaints, ROS, HPI, PFSH, and Physical exam clearly in dictation.  One extra detail could mean a higher level!

Erroneous diagnosis dictations cause delayed claims – Watch out for dictation mistakes on the diagnosis level.  For example, if a patient comes in for right ankle pain and the x-rays are dictated as left ankle x-rays which continues to the plan of care section, the coder will have to put the claim on hold and get an addendum made to clarify which ankle was actually examined.  Coding errors could delay the claim timely if not done promptly. 

How to improve accurate and timely coding

We believe Specialty providers deserve specialty coders.

At MEREM Healthcare Solutions, that is what we provide to Orthopedics and Sports Medicine practices. Every client deserves the expertise of experienced CPC coders. That is why we employ COSC coders for their specialized knowledge pertaining to complex orthopedic surgical cases.

CPC certification by the AAPC has become the gold standard with additional specialty certification available such as AAPC’s COSC (Certified Orthopedic Surgical Coder).

Get reimbursed faster by turning to an experienced team of certified professional coders to improve accurate and timely coding for your practice. Whether you scribe dictations or utilize an intuitive EMR, MEREM Healthcare Solutions tailors our coding strategy to fit the specific process used for your specialty physician documentation and will also assign and develop our coding staff around your specialty.

Charge Optimization

Working to implement the standard of including as much detail as possible is the first steps toward documenting iron-clad operative reports. Op notes are never written in stone, but the sooner they are finalized with as much information as possible, the sooner it can be coded and paid.

Improved documentation results in revenue improvement. Accurate coding results in faster reimbursement. With detailed documentation, coders don’t have to rely on addendums and delay processing claims. The turn around is quicker and more effective for the physician to be paid.

The coding team at MEREM Healthcare Solutions is trained to help your practice maximize billed charges. By reviewing every encounter note and operative report, our specialty coders will prevent under-coding and over-coding to ensure that every billable procedure performed is correctly reported. Additionally, our consulting team can help you increase charges by maximizing your clinic output and improving documentation quality.

The post Next Level Coding Begins with Improved Documentation appeared first on MEREM Health.

When the American Recovery and Reinvestment Act was approved, all healthcare providers (both public and private) were required to adopt the use of electronic medical records (EMR). Since January 1, 2014, EMR systems have assisted several healthcare organizations in maintaining health-related information on patients, as well as improving workflow and the quality of care provided to patients and their safety.

Unfortunately, though, adoption of EMRs across America has been low, which is why it is vital for all healthcare organizations to realize the importance and extensive need of EMR systems in all medical practices within the United States.

Is Your Medical Practice Utilizing an EMR?

When it comes to patient care, there are many medical “players.” An EMR system allows for communication on a patient to be had in one, centralized location, which also includes all services billed on the patient by each medical professional.

“An EMR system is extremely important for billing purposes, especially since it provides an audit trail of all necessary documentation,” explains Jennifer L. Smith, CPC, Director of Billing Operations at MEREM Healthcare Solutions. “With so many people involved with the patient, it is easier to be able to electronically locate medical records, authorization/referral approvals, records release, and payment receipts. All paperwork involving the patient and his or her care should be accessible at any time by anyone involved with the care of the patient.”

The Benefits of an EMR

If your medical practice has yet to utilize an EMR for its medical practice, what are you waiting for? Particularly since there are several benefits associated with an EMR system, including:

• Easily accessible for all parties
• Provides an audit trail (if needed)
• Eliminates the need for paper charts since everything is electronic

It is important that when an EMR system is being used, the process and/or workflow designates a person(s) to upload documentation daily, including what type of documentation and where it should be uploaded.

Avoid EMR Issues with Our Help

As with anything, the EMR system has some cons. However, even with the risks associated with an EMR system, medical offices can prevent problems with billing, coding, and other areas by:

• Making sure to have signed documentation from the patient regarding release of information,
• Staying within HIPAA compliance, and
• Verifying all necessary information on accounts.

Of course, even with an EMR system in place, it is good practice to have a backup via a paper chart or a computer disc in the case of a power outage or technical failure.

“MEREM Healthcare Solutions can assist with issues associated with EMR and billing among medical facilities,” Smith explains. “Our team can help implement processes and workflows regarding your EMR, ensure your medical practice remains in HIPAA Compliance, and send out notifications regarding missing documentation.”

At MEREM Healthcare Solutions, we want to be your strategic partner in making sure your billing, coding, auditing, and other needs are met. Contact us today to learn how our knowledgeable and experienced professionals can help assist with issues associated with EMR and billing among your medical facilities.

The post The Vital Role EMR Plays in Medical Billing appeared first on MEREM Health.

Clinical documentation is at the core of every patient encounter. It is to document the care provided to the patient, as well as to communicate with other providers. In order to be meaningful, it must be accurate, timely and reflect the scope of services provided.

Elaborate on Quality of Care

Make clinical documentation improvements about quality! When improving clinical documentation, physicians should focus on the opportunity to validate and expand on the quality of care provided.

Markups Are Not Recognized Documentation

Fee tickets and superbill markups are not considered valid documentation and are not recognized in an audit. E/M levels, procedures, and diagnostic readings must be documented in order to reflect the quality of care and services provided.

Remember, If you did not document it, it did not happen!!!

Organizations need well-rounded individuals who can effectively articulate all the pieces:

• documentation requirements
• code assignment
• coding guidelines
• quality reporting

MEREM Healthcare Solutions can help!

Visit our website at Meremhealth.com for more information and be sure to take the opportunity to schedule a free consultation with Merem Health.

MEREM Healthcare Solutions is a Birmingham, AL-based company that has been providing exceptional medical billing and coding services to physician practices and ambulatory surgical centers since 2008.
We pride ourselves on not just maintaining, but exceeding, the level of accountability, communication, and customer service that is valued in traditional, on-site billing departments.

Please check out our other blog posts, or contact us to learn more.

The post Validate Care Quality via Procedure Documentation appeared first on MEREM Health.