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Use EMR to Make Billing Easier and More Accurate Proceed with caution for best results BY ROBERT KURTZ


A n electronic medical record (EMR) system can be a valuable


tool in helping ASCs improve their billing performance, says Nanette Reintges, founder and principal con- sultant at Finance and Information Technology Performance Strategies, a consulting firm in Odenton, Maryland. It is vital, however, that use of the EMR does not streamline documenta- tion to the point where potential prob- lems can occur, she cautions. “ASCs must walk the line because you cannot use robust templates that include every option under the sun and then just ask your surgeon and circu- lator to check boxes,” Reintges says. “That may get you into trouble with the Centers for Medicare & Medicaid Services’ (CMS) auditors and other payers. When constructing clinician documentation, you need to follow the guidelines for reimbursement.” While ASCs must be careful with


how much they lean on their EMR to streamline documentation, appropri- ate use can help get accurate claims out fast, Reintges says. That was one of the objectives for Spring Creek Surgical in Providence, Utah, when it purchased and implemented an EMR, says Darcie Card, RN, the ASC’s nurse administrator. To help accomplish this goal, she


says the ASC spent four months edit- ing its EMR so the documentation involved would meet the ASC’s exact needs. “We reviewed and edited every single page, taking out every- thing we did not need for our ASC and surgeons. This helped simplify the documentation process. Once our physicians complete a procedure, they can go into the EMR and review the surgery performed and verify it. They also have the ability to eas- ily edit the documentation to reflect exactly what they did.”


The ASC’s circulator also verifies information at the end of the procedure and makes sure what is documented in the EMR accurately reflects what was performed, Card says. “Our billers are confident that since the surgeon and circulator have this easy means of doc- umentation, what they are billing for has been reviewed and verified.” The verification process is critical, Reintges says, especially, when the EMR is pre-populated with informa- tion when the case is scheduled. “Just because someone is scheduled for one procedure does not necessarily mean that is what happens—or only what happens—in the operating room.” She notes that sometimes either


surgeons or circulators fail to update their documentation to reflect changes in a procedure. “That is problematic as nursing documentation—the EMR intraoperative record—and the cli- nician’s documentation—the opera- tive note—must support one another. A nurse cannot document the opera- tive note for a physician, and docu- mentation cannot ever be copied—or ‘cloned’—from one report to another.”


30 ASC FOCUS APRIL 2018 |www.ascfocus.org


If ASCs want to ensure proper reim-


bursement, Reintges adds, the docu- mentation should note all the supplies used during the procedure. “I have worked with an ASC that was omitting supplies from its documentation, citing time constraints and lack of payment for those supplies as justification. The problem is that, oftentimes, those sup- plies support the complexity of what the ASC is billing for. The use of a sup- ply can make the difference between a complex and simple procedure and affect your reimbursement rate.” Card says the EMR has been a differ- entiator for her ASC, noting that surgeons appreciate the ease of use that helps them complete their documentation fast and get the facility paid appropriately. “We are in a town with several com- petitors for their services,” she says. “We constantly hear how much they appreci- ate that our EMR is simple and straight- forward compared to the systems at other facilities. It took a lot of work to modify the system, but I take pride in how much our effort has paid off.”


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