Documentation template prompts thoroughness
ED managers who don't currently use a documentation tool that prompts you to take actions that will ensure optimal reimbursement are missing an opportunity to significantly enhance revenues, says Robert B. Takla, MD, FACEP, vice chief — emergency services at St. John Hospital and Medical Center, Detroit.
Any time there is not a complete review of systems, Takla notes, you are at a disadvantage. "You can't code for a Level V visit unless you meet a certain number of body parts examined, so the exam needs to be more complete," he notes. So, for example, if a patient presents with pink eye, you would not be expected to do a complete head-to-toe exam, but if someone presents with chest pain, "my system ought to prompt me to do a complete head to toe — head, ear, eyes, nose, and throat, a chest exam, a lung exam, an abdominal exam, an extremity exam, and a neurological exam," Takla says.
As you go through those systems, he explains, the more that are included, the more consistent the record will be with billing up to a higher appropriate level of service. "Often this is not done if there is no prompt," he notes.
One system named Emergency Mapping (E/MAP, Lynx Medical Systems; Bellevue, WA) is gender-specific, age-range specific, and complaint-specific, notes Takla. "It is uniquely bar-coded for that patient and encounter, and melds complaints together in such a way that it will generate appropriate questions and physical exam areas one should be concerned with," he says. "Someone left at their own discretion will pick up a Dictaphone, and if they are in a hurry, they will tend to do less. And if you do less, you can only appropriately bill and collect for less."
Resource
For more information about Emergency Mapping (E/MAP), contact: Lynx Medical Systems, Bellevue, WA. Phone: (425) 641-4451. Fax: (425) 562 4860. Phone: (800) 767-5969. E-mail: [email protected]. Web: www.lynxmed.com.
ED managers who don't currently use a documentation tool that prompts you to take actions that will ensure optimal reimbursement are missing an opportunity to significantly enhance revenues, says Robert B. Takla, MD, FACEP, vice chief emergency services at St. John Hospital and Medical Center, Detroit.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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