Documentation template prompts thoroughness

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."

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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.