30 May Electronic Records and Medical Billing Audits
In the past 15 years, the medical profession has turned to using laptops and tablets to record their interactions with patients. Software has been developed that combines SOAP notes, medical coding, and billing into a form that serves physician, coders and billers, payers, and patients.
Why Electronic Records Are Better
Electronic records offer healthcare providers, coding and billing agents, and payers numerous benefits. They make it much easier to take and share notes and important data. Unlike handwritten notes, there’s a consistency in terms of readability. They are easily corrected and are a neat and tidy way to record and store information. As long as records are stored properly, they are virtually indestructible.
How Comprehensive Should They Be?
SOAP notes, which are a major aspect of electronic record keeping, document the healthcare provider’s subjective and objective observations, assessment of the patient, and a plan for treatment. The division of the notes into these categories allows for an orderly thought process and helps to facilitate communication.
Subjective observations include the patient’s complaint or their reason for seeking medical attention. Also, a medical history is an important part of this section as is the noting of any loss of function or pain the patient is experiencing. In the second part, objective data includes the measurement of vital signs, results of lab tests, and recording of medications the patient is taking.
The third section, which is the assessment, is usually two to three sentences long. It may include a diagnosis, reason for admission into the hospital, assessment of medical issues related to the complaint, recent surgery, or progression of a disease or injury. The Plan section is where you document the actual treatment regime, which may include lab tests, monitoring of patient, surgical procedures, or nonsurgical approaches. You might also document referrals to a specialist or other healthcare providers and what was discussed with the patient.
It’s important that electronic records are carefully monitored for mistakes or incompleteness. Mistakes can easily occur as medical data may be entered incorrectly, the wrong codes indicated, or information related to patient ID, insurance provider details, or other aspects used to identify patient, provider, or payer are incorrect. Also, because a patient’s record must be updated, as certain aspects may be filled in during a visit, and others after tests are complete, it’s easy to end up with incomplete records. Thus, tracking each patient and their record must be done carefully and completely.
It is important that all information in each patient’s electronic record be properly recorded, saved, and stored. Timely communication with your medical coding and billing personnel will help ensure that claims are processed correctly the first time. If you are audited, having records that are comprehensive and complete for every patient and every time they were seen is essential. Electronic records are powerful tools when they are used properly and as intended. Take the time to utilize them to their fullest and you will have everything you need to survive an audit.