We recently attended the annual meeting for the Carolinas Medical Directors Association in Charlotte, NC. One of the sessions focused on the challenges of billing for Medicare according to requirements set by the Centers for Medicare and Medicaid Services (CMS). Producing compliant notes and selecting the correct evaluation and management (E&M) code is a problem that vexes many practices today. Although the presentation was focused on the long term care environment, the information here should apply to most practices. We will focus on three main components: medical necessity, documentation requirements, and patient complexity.

Medical necessity is the most basic and important criteria. Each note should contain a rational, medical explanation for why you are seeing the patient. This is most often documented under the chief complaint. Physicians should be careful to use active verbiage in their notes. For instance, physicians should avoid using “reviewed” in favor of “assess,” and substitute “patient continues to exhibit…” instead of “stable.” Determine, measure, evaluate, verify, and examine are examples of good words to use. Use active voice in your notes instead of passive. For example, instead of saying “was reviewed,” state “I am instructing the nurse to measure.” The entire note should show the medical necessity of your visit and support the chief complaint.

In addition to medical necessity, CMS requires a certain amount of documentation for each E&M code. Generally speaking, higher levels require more documentation. Chief complaint is required for every level. Your note should have sections for history of present illness (HPI); past family and social history; physical exam and review of systems; and medical decision making. For example, an expanded level of coding generally requires at least four areas of HPI. Including information for each of these required areas can help you bill higher levels. If you are audited, CMS will look for each of these categories in your note.

Patient complexity is determined by risk and medical decision making. The more complex your patient is, the higher you can generally bill. For instance, if your patient suffers from an ingrown toenail, you won’t be able to code very high. On the other hand, if your patient has “one or more chronic illnesses with sever exacerbation or progression,” then you will qualify for a higher level. Also be sure to document work you do, such as reviewing or ordering lab tests, obtaining old records, etc. It can have a substantial impact on your coding and compliance.

Purchasing an electronic medical record (EMR) will help you code correctly and produce compliant documentation. Hand-written or dictated notes are often incomplete or illegible, but an EMR can help you fill out required information and pass an audit. In addition, an EMR can help you capture previously undocumented work you already perform. As a result, you can usually code at a higher level, leading to better reimbursements. If you are still using paper, now is the time to switch to EMR.

If you would like to test your coding knowledge, take our short quiz.

Department of Health and Human Services (HHS) Secretary Kathleen Sebelius released an important report last week. The report finds that implementing health information technologies, like electronic health records, can help improve health care quality in rural areas. Specifically, the report examines the Columbia Basin Health Association (CBHA) in Othello, Washington, the technologies they implemented, and the resulting improvements in healthcare.

According to Secretary Sebelius, the CBHA is just one example of how “health information technology and electronic health records (EHR) have helped ensure patients get better care.” She goes on to report that technologies like EHRs “can reduce paperwork, make care more efficient, and let doctors spend more time practicing medicine and less time filling out forms.” In addition, many practices are financially better off after implementing an EHR, because the resulting efficiencies can reduce operating costs and allow practices to see more patients.

As a case in point, CBHA used their electronic systems to track diabetic patients. Prior to implementing their EHR systems, only 31% of CBHA’s diabetic patients received their recommended foot and only 37% their eye exams. After implementing their EHR, the numbers rose to 86% and 63%, respectively. In addition, CBHA now ranks in the 95th percentile nationally for total medical and dental productivity.

While implementing EHR systems can benefit any practice, rural areas seem to have the most to gain. Many rural areas fall under federally-classified “Health Professional Shortage Area,” which means there may not be enough physicians to satisfy local demand. EHR systems can help physicians in these shortage areas by allowing them to see more patients per day without an increase in overhead.

However, physicians in rural areas should be careful when selecting an EHR system. Many rural areas lack critical infrastructure that could pose a challenge to implementation. High speed internet, for instance, is still not available in all areas. Similarly, physicians may have trouble finding qualified computer support technicians. Office staff may lack basic computer skills, which can slow down implementations and require more expensive training.

Despite these limitations, rural physicians should continue their EHR search. Instead of purchasing one of the complicated, expensive market-leading systems, physicians should purchase a simple, cost-effective EHR that doesn’t require a full-time internet connection. Simple systems are easier to install, and easier to learn and use, especially for physicians and staff with little computer experience. Last but not least, the HITECH stimulus act offers increased EHR reimbursement payments for physicians in rural “Health Professional Shortage Areas.”