EHR systems have changed over the last decade and the health reforms have given new meaning to such systems by making rules regarding ‘Meaningful Use” (MU) of such systems. Older versions of EHRs were simple digitized versions replacing paper based records and did not have the specific guidelines in MU to be implemented for the incentives. However, almost all EHR vendors now are MU compliant but only 10.1% of physicians in the country have a fully functional EHR system. This is due to the fact that those who have a basic system are not equipped with features to handle MU compliance along with the changing face of the health industry including the attitudes of payers towards billing processes.
A report prepared by the University of North Texas on providing – Guidance in Documentation, Coding, and Billing of Medical Services for Compliance- clarifies the documentation and billing requirements and also the general rules to be followed while documenting. For instance – the medical record should be complete without any errors and the documentation of each patient should include the reason for encounter, relevant history, prior diagnostic test results, and physical examination findings. The past and present diagnoses should be accessible to the consulting or treating physician, the patients progress is to be documented and appropriate health risk factors identified. The code reported on the claim form or billing statement needs to be supported by documentation in the medial record.
Hence the requirement for a separate billing system can be felt and is one of the solutions for such complex compliance requirements and the above subset of information can be sent to a billing system designed to specifically handle such information. There are numerous other documentation standards that need to be observed and these standards are easily handled by EHRs and can be made to fit the billing system. The information corresponding to all the documentation standards mentioned above can be sent directly to the billing system at the time of the visit, making the whole process smoother. Moreover, HIPAA compliance can be easily observed because the medical documentation is stored in the billing system and does not require the clerical staff to access the actual EHR.
Billing and related processes need to be reorganized to fit the requirements of not just MU compliant EHR systems but also for accurate and timely reimbursements. These documentation standards and compliance are extremely important in light of the way in which payment models are changing in the industry. Physicians would be paid according to the quality of the service provided and the outcomes rather than the traditional per-patient method. For more information about medical billing processes and to restructure your billing and assistance with EHR implementation, visit www.medicalbillersandcoders.com, the largest consortium of medical billers and coders in the United States that also provides services such as revenue cycle management, denial management, and consultancy.