The multitude of benefits with an EMR include improved documentation standards, better capture of work performed, enhanced patient care and productivity and higher reimbursements. As healthcare practices race to meet the EMR implementation deadline, it's important that physicians have realistic expectations about what EMRs can and cannot help them accomplish. One thing is certain – EMR is not a suitable substitute for medical coders.

 

What Physicians Should Know About Claims Processing with EMRs

EMR is a tool, not a solution. EMR cannot help physicians code higher and earn higher reimbursement, as some EMR vendors are claiming. As an article in the American Academy of Professional Coders (AAPC) Coding Edge magazine (2010) points out, EMRs can help with reimbursement, but they cannot stop claim denials in the future.

Before the advent of EMRs, medical coders would generate clean claims from physician documentation of medical charts or superbills. The coding expert ensured that the claim was processed to according to the coding rules of government and private payer regulations. When EMRs came into the picture, things changed. EMRs have claimed to automate this process in a way that should not be done. EMR documentation tools feature procedure and diagnosis codes.  When a physician enters information relating to a patient visit into the EMR, the system automatically generates superbills with the relevant code data. This means the physician inadvertently becomes the coder. The system automatically sends claims directly to the payer or clearing house. This is extremely risky as far as efficiency in claims processing is concerned.

Medical coding is a highly complex procedure and not something that can be easily automated. Carriers will not pay unless they are convinced that the service provided was medically necessary and that the submitted claims are perfect in all respects. Though the physician documents the patient visit down to the last detail, the claim would still not be ready for submission. EMRs are not designed to integrate any clinical information that impacts coding into the superbill that the EMR automatically generates. A professional medical coder's services are indispensable when it comes to editing the claim before it is submitted to the health insurance carrier for payment. Mere code selection cannot ensure proper reimbursement.To date, no EMR software has the capacity to fully automate the coding actions necessary for accurate claims processing.

Limitations of EMR Coding Tools

Claims scrubbing is a crucial factor in claims processing. Many EMRs add on a code scrubber to scrub medical claim files for accuracy before submission. Code scrubbers are designed to review claims for issues such as valid ICD-9, CPT® and HCPCS codes, add-on codes missing parent codes, improper use of modifiers, missing diagnosis, HCFA rules for reporting multiple procedures, and Relative Value Units. However, what these scrubbers cannot do is what matters.

Code scrubbers in the market cannot check claims based on commercial payer guidelines, HCPCS rules (or DME requirements), patient demographics and age or gender-based code selection, provider credentialing, referring doctor, accident dates, and multi-level code comparisons. A professional medical coding company can. Efficient claims processing and scrubbing is performed to validate all patient demographics, CPT/ICD9, HCPCS code combinations, checking of the against National Correct Coding Initiatives (CCI) edits, Medically Unlikely Edits (MUEs), frequency allowances and all of the areas where the claims scrubber tool falls short of expectations. Claims are processed for payment only after all information is double-checked.

EMRs will continue to develop. However, even the most technologically advanced software will be unable to accomplish what human intervention can. Physicians, clinical personnel and front office staff must be trained to use EMRs efficiently to improve workflow. Medical coding and claims submission processes are practice-specific and cannot be done on the front-end. ICD-10-CM will increase documentation activities. The services of third party providers are invaluable when it comes to reducing the documentation and coding burden of healthcare practices.