There have been numerous advancements to the medical profession to assist medical providers in their day to day billing and clerical tasks, but there has been no other advancement as competitive marketed as the ever-expanding practice management system software available to us today.

Healthcare providers have become inundated and often times overwhelmed with the variety of choices and functions that these systems are capable of to assist in their documentation efforts, but providers must be aware that many of these functions that seem as though they are at the top of the game, can in fact be problematic with their reimbursement and liability of their documentation.

Practice management systems often have pre-populated template abilities, and macro building functionality in order to cut down on the amount of information a provider must manually enter in, therefore decreasing the amount of provider administration time in completing their documentation and charting. Auto-normal functionalities and automatic importing from previous visits seem as though they are helping, but in fact can open up a provider’s practice as a target for payer audit findings.

Providers must remember that in the event of an audit or a patient record request from an insurance company for claim processing, it is crucial that their selected record for review must not appear to have any cloning, and/or information that would in no way be pertinent to the patient involved. There are many macros and templates that would be specifically made for each sex, specific age groups, etc. that can be inadvertently imported into a record if a provider is not careful.

To minimize this exposure risk, it is imperative that providers understand the importance of making sure that their entire record for the visit isn’t just a templated version of the visit type. They must be sure to include their own free text wording, especially when it comes to HPI, Assessment and Plans. A templated software function does not have the ability to do cognitive thinking that is crucial to a provider’s management of the patient’s condition, and therefore could easily miss out on the fullness of documentation that is needed to prove medical necessity in the leveling of evaluation and management service.

To have a template of ‘All Systems Reviewed and normal’ when a patient has presented with an relatively acute condition, will often trigger audit findings due to there being no medical necessity in reviewing all systems when the patient may only be presenting for a specific illness such as sinusitis for example.

While software companies will advertise and push their systems for these state of the art technologies, providers can rest easy that they will maintain compliance with their billing requirements by utilizing the functions wisely, and making sure that each patient documented for has specific wording and reference to their personal situation.


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