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FAQ

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1)      What are ASA’s criteria for Intelligence in Medical Records (IMR)?

2)      What is the fundamental structure of IMR?

3)      Since IMR incorporates all the relevant rules of CPT and “Documentation Guidelines” relevant to each type of encounter, do physicians need to consider any other rules outside of E/M coding and Documentation Guidelines?

4)      Why does “medical necessity” form the foundation of IMR?

5)      Why is documentation a critical component of medical care and coding?

6)      Are there any common documentation formats that may prove questionable on audit?

7)      What have been the results of Medicare and insurer audits of ASA’s IMRs?

8)      Can IMR impact physician reimbursement?

9)      What are the benefits of IMR for patients?

10)  What are the benefits of IMR for physicians?

11)  What are the prospects for AMA and CMS discarding Documentation Guidelines and moving to “Vignettes” as the templates for coding?

12)  Can dictated medical records be modified to be intelligent?

13)  Can electronic medical records (“EMR) be modified to be intelligent?

 

1)   What are ASA’s criteria for Intelligence in Medical Records (IMR)?

a)     Accurate E/M coding plus compliance with all “Documentation Guidelines” with no need to memorize or look up coding rules”

b)   Patients complete check boxes for significant portions of the medical history

c)      Medical records are audit-proof

d)      Decreased hassle factor for physicians

e)      Increased patient care efficiency

f)      Enhanced quality of medical care

2)      What is the fundamental structure of IMR

a) IMRs are built on a framework of the E/M coding system and “Documentation Guidelines.” Specifically, all the elements of documentation and coding are automatically built into the medical record. This includes all the components of medical decision making plus documentation of medical necessity.

b) Physicians do not have to memorize or look up any coding or documentation “rules”. All rules are incorporated into the IMR and appear as coding prompts

c This framework is then enhanced with details customized to each specialty and each physician.

d) IMR includes all seven elements of E/M coding. Most particularly, IMR focuses on medical necessity (in the form of “nature of the presenting problem”) as the cornerstone of determining the level of care warranted by each patient’s illnesses. coding prompts then guide the physician to insure proper performance of care and documentation to support the appropriate, optimal E/M codes

e) IMR augments Physician efficiency:

i)  Patients complete much of the past medical history and review of systems by documenting responses to questions formulated by the physician

ii) Check boxes allow rapid documentation of all normal findings of the physical examination

iii) Check boxes allow rapid documentation of data reviewed, data ordered, and information materials provided to the patient

f) IMR enhances quality of care by assuring comprehensive history, patient-appropriate examination, patient-appropriate medical decision making, and accurate documentation to allow efficient on-going care of the patient

3)      Since IMR incorporates all the relevant rules of CPT and “Documentation Guidelines” relevant to each type of encounter, do physicians need to consider any other rules outside of E/M coding and Documentation Guidelines

a) ASA teaches physicians to appreciate only two rules these rules are both are fundamental to CMS (aka HCFA) and insurers:

i) If care was not documented, it is considered that the care was not performed

ii) If care is not medically necessary, the code should be decreased to the highest level of care warranted under medical necessity (as defined in CPT)

4)    Why does “medical necessity” form the foundation of IMR?

a) Fundamentally, Medicare and insurers will only reimburse for care that is “medically necessary.” CPT defines Medical Necessity by the “nature of the presenting problem.”

i) Appendix D of CPT lists clinical examples of medical necessity associated with different levels of E/M care

ii) Since medical necessity is a critical component of compliance, IMR guides early selection of the appropriate E/M code level based on coding prompts related to the nature of the patient’s problems

iii) IMR then provides coding prompts to guide the physician in performing and documenting the level of care appropriate to support the selected E/M code and warranted by the patient’s illnesses

5)       Why is documentation a critical component of medical care and coding?

a) One of the rules that is fundamental to CMS (aka HCFA) and insurers is that if care was not documented, it is considered that the care was not performed

b) Good documentation assures that appropriate care is performed and facilitates appropriate quality of care on patient follow-up visits.

6)        Are there any common documentation formats that may prove questionable on audit?

a) A common questionable format lists a series of medical symptoms and then instructs the patient to “circle any symptoms you have.” Unfortunately, for un-circled symptoms there is no documentation that the patient read or understood that particular symptom. When all symptoms are left un-circled, there is no evidence that the patient even read the page.

b)  Standardized dictation templates, if not properly formatted, document only that a word processor can print what has been programmed.

c)  Electronic medical records that default all responses to negative do not adequately document that the care was actually performed

7)     What have been the results of Medicare and insurer audits of ASA’s IMRs?

a)To date, IMRs have successfully passed every audit on every chart.

8)     Can IMRs impact physician reimbursement?

a) IMR has a two-fold impact to correct improper coding:

i) IMR coding prompts guide selection of the appropriate E/M code on the basis of medical necessity.

ii) IMR coding prompts then guide the level of care and level of documentation appropriate to support the properly-selected E/M code.

9)       What are the benefits of IMRs for patients?

a) IMR assures appropriate level of medical care for nature of their illnesses

b) Comprehensive past history, social history, family history, and review of systems, documented by the patient, assure that the physician will have a comprehensive background of the patient’s medical history and health

c) Documentation efficiencies allow the physician more time to attend to the patient and discuss recommended care

10)  What are the benefits of IMRs for physicians?

a) Compliance with documentation and coding requirements

b) Excellent compliance when audited

 c) Optimized coding and reimbursement by matching level of care performed and documented to the nature of patients’ illnesses

d) Increased efficiency of care

e) Enhanced quality of care

11)   What are the prospects for AMA and CMS discarding Documentation Guidelines and moving to “Vignettes” as the templates for E/M coding?

a) Even the limited “vignettes” presented as clinical examples in appendix D of CPT have proven too cumbersome to be useful while evaluating patients

b) In 1999, a significant attempt at implementing vignettes failed to meet physician care requirements

c) ASA feels strongly that subjective vignettes create greater difficulty for physicians in both documentation and coding, while the IMR approach facilitates documentation, efficiency, quality of care, and compliance

12)   Can dictated medical records be modified to be intelligent?

a)   ASA has incorporated all the features of the IMR into templates that can be employed by both the physician and the transcriptionist

b)  This can save transcriptionist time (and therefore expense) by having much of the verbiage of the record pre-programmed into the word processor

c) ASA provides an option for further efficiency by combining the dictated portions of IMR with a paper format for sections of the medical history that the patient can self-complete

13)  Can electronic medical records (“EMR) be modified to be intelligent?

a) ASA has discussed this concept over the last eight years with a number of companies producing software for EMR.

b) Some companies have incorporated “coding engines” to calculate the level of care documented in the chart.  However, these software programs lack several of the critical features of the IMR. Specifically, ASA is not aware of any company that has incorporated the critical insight of using medical necessity as the foundation of the documentation and coding. Therefore, in these systems there is no guidance in selecting the E/M code appropriate to the nature of the patient’s illnesses, and further there are no coding prompts to guide the level of documentation required to support the appropriate E/M code level.

 

 

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• Compliance

• Efficiency

• Reimbursement

• Audit Proof

• "Sleepability"



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What is the fundamental structure of an IMR?

What have been the results of Medicare and insurer audits of ASA’s IMRs?

What are the benefits of IMRs for patients?



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Using check boxes, your patients complete all elements of the past medical history, family history, and social history, plus a complete review of symptoms

This results is a time savings to physicians of approximately 10 minutes per patient.



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