Bridging the Gap

Electronic encounter forms create a critical link between practice management and electronic medical records systems.

When it comes to implementing electronic medical record (EMR) systems, cost is most often cited as the primary reason for slow adoption, particularly among smaller practices. However, cost isn’t the only source of resistance; many are unsure of what to do with their existing practice management (PM) systems. Their options include:

Purchase an EMR and run their PM separately: This requires maintenance of two systems with separate databases, and may still require duplicate data entry, defeating a major benefit of an EMR.
Purchase an EMR and interface it with the PM system: Although appealing, building an interface can be expensive and cumbersome.
Replace the existing system with an integrated EMR/PM: This is the most expensive option. However, it is the best way to proceed if an interface is unrealistic.

Electronic encounter forms create a critical link between practice management and electronic medical records systems.

Jamie Loehr, M.D., is the founding partner of Cayuga Family Medicine, Ithaca, N.Y.

Purchase an EMR and run their PM separately: This requires maintenance of two systems with separate databases, and may still require duplicate data entry, defeating a major benefit of an EMR.
Purchase an EMR and interface it with the PM system: Although appealing, building an interface can be expensive and cumbersome.
Replace the existing system with an integrated EMR/PM: This is the most expensive option. However, it is the best way to proceed if an interface is unrealistic.

In my opinion, implementing an integrated system is the best way to realize maximum benefits. These include sharing a registration process that brings together the financial, clinical and logistical aspects of patient care, enhanced ease of use, and easier set-up, training and support.

One of the key benefits of an integrated PM/EMR is the electronic encounter form (EEF), a powerful yet understated tool that has significantly impacted my own practice. Essentially, the EEF automates sharing of clinical and billing information between the EMR and PM applications. The EMR can automatically insert billing codes and diagnoses into any progress note. Once the progress note is signed, the EMR automatically transfers the appropriate ICD-9 and CPT codes to the billing system in the form of an EEF. The billing clerk or office staff can quickly review the EEF (and any physician progress notes), then validate and post the charge for automatic billing.

The physician can also create “action codes” in the progress note. When included in the EEF, these action codes communicate the need to schedule labs, X-rays or a specialist referral so they can be managed as part of check-out.

Finally, the EEF can be customized to ensure the most commonly used diagnoses, billing codes, modifiers and action codes are readily available, streamlining the process.

A Personal Experience
Cayuga Family Medicine is a low volume practice that focuses on pediatrics and obstetrics. Our two physicians and one nurse practitioner work part-time and see a combined total of about 50 patients a day. We implemented an integrated EMR/PM system from Practice Partner, including Patient Records, Appointment Scheduler and Medical Billing, when we opened our doors in 2000.

In the beginning, the system served mainly as an electronic version of the patient chart, providing a convenient way to store data without duplicating information between databases. The templates provided by the system were convenient for progress notes, but we did not link the clinical and billing information—something I would have done immediately had I realized the role the EEF could play in streamlining productivity and improving billing.

As the partner responsible for our IT systems, I was a frequent visitor to the Practice Partner listserv—a goldmine of information from other users on maximizing use of the software—where I learned about connecting the EMR and billing system through the EEF.

After a bit of homework, including talking with our staff about information that would be most beneficial, I spent a day creating progress note templates that included approximately 300 text notes, common codes and various modifiers required by insurance companies. Within a day of implementing the EEF, the majority of our staff was completely comfortable with the new and improved workflow.

For the majority of visits, the process is very straightforward. If I am seeing a three-year-old for a well child check, I open the appropriate note template. At the top of the note, I choose between one of three obviously-named text macros (quicktext items) which expand out to additional text. These quicktext items are built into the template (Figure 1) and, when chosen, cause the billing code to automatically expand out and tell the system which billing and diagnosis codes to use. When I sign the note, that information is sent directly to the billing system.

Another common visit is a sick visit. After entering the history and clicking on the appropriate exam choices, I find several options for billing at the bottom of the note (Figure 2). I choose the quicktext item for the level of visit, then choose a common diagnosis from the list. After I sign the note, the information is immediately shared with the billing system.

If the quicktext item for the diagnosis is not in the list at the bottom of the note, we have an easily accessible list of 50 or more diagnoses (our “easy diagnosis list”) that can be inserted with a few keystrokes. Each quicktext is obviously named, making it easy to find the right code. If the diagnosis is rare, we can search the ICD-9 listings in our system or just leave a note for our billing staff to look it up.

Benefits
We realized a number of immediate benefits, including increased productivity due to the elimination of duplicated efforts. In the past, I would circle codes on the paper superbill and pass it along to the front office staff. They would call up the account in the billing system and enter the code by hand before sending it off to our clearinghouse. Now, I enter the codes on the EEF and my staff needs only to verify, rather than re-enter, the information, and the charge posting is automatic.

The EEF markedly reduced the risk of typographical errors. In the past, if the billing staff entered a 99393 (well child check 5-11) instead of a 99392 (well child check 1-4), we wouldn’t catch it until the denial came back. Now the information is fixed in the template, reducing possible mistakes.

Another benefit is a dramatic reduction in missed charges and denied claims. Before, if something wasn’t circled on the superbill, it wasn’t billed. Now, because of our templates, proper documentation is automatic. The best example of this is the vision screen at well child checks. In the past, we forgot to circle the vision screen code nearly 80 percent of the time. Now the quicktext item for that code is automatically included, and I only have to click on it to bill, resulting in a 90 percent capture rate.

By including billing quicktext items in our progress note templates for rapid strep tests, urine pregnancy tests and Depoprovera shots, for example, our nurses are able to easily and accurately document encounters and capture charges with just a click or two.

The most important benefit relates to administering vaccines. There are more than a dozen different ways to bill vaccines in New York, and several insurers have their own set of complex rules. In the past, we would often get denials because, when entering the paper claim into the computer, the biller would forget to check the child’s age or if it was Medicaid or private insurance. Now, with our integrated system, the nurse simply documents the vaccine and picks the patient age, insurance and whether it’s the first or second vaccine administration. The progress note automatically selects the appropriate codes and modifiers and the system creates an EEF, resulting in a clean claim.

Currently, more than 98 percent of our claims go through EEF. The only exceptions are the very rare codes that are not on the “easy diagnosis list” and skin lesion removals. The latter require a pathology diagnosis, so the note is finished on the day of the visit, but the billing is hand-coded when the pathology report comes back.

An Immediate ROI
Implementing the EEF had a significant impact on our bottom line. In exchange for a few hours of my time, we were able to improve productivity, reduce denied claims, and save on additional staff and outsourced services.

Before implementing EEF, we considered outsourcing billing or hiring an additional part-time billing person. Outsourcing would have cost 7 percent of our revenues; hiring would have cost $20,000.

Since implementing EEF, a large chunk of my biller’s work has been moved to front desk staff. Because they are only validating claims, they are able to review and submit charges during quiet times and send them to the clearinghouse. This also helps with turnaround time. My biller used to be so busy that claims were only sent weekly; the front desk can easily do it three times a week.

As for denied claims, the reduction in errors is tremendous. New York Medicaid, our pickiest payer, requires a special SL code for vaccines. We missed this modifier 25 percent of the time on hand-entered claims. Now the SL modifier is hard-coded into the template; the only way to make a mistake is by choosing the wrong insurance. That still happens, but much less often.

The tools available through an integrated system not only improve productivity, but also speed the revenue cycle and enhance revenues themselves by capturing previously missed charges and reducing or eliminating denied claims. The return is well worth the initial investment for a practice of any size.

November 2006