It’s all about money! Between the HITECH Act of February 2009 and the recession (which we’re told actually ended last year – who knew?), the pressure is on hospitals to shorten the revenue cycle and to make it more efficient and effective – the end goal being more dollars coming in faster.
After a healthcare provider has dictated a report describing the patient encounter, the completed document, after having been signed by the physician, then resides in either an EMR/EHR, in some other electronic form, or on paper.
Once either on-site or off-site coding staff has assigned CPT and ICD-9 codes, the bill is then generated by either, again, the Billing Department or outsourced billing company (revenue cycle management vendor). If done in-house, patient account specialists, patient account managers, and outpatient or inpatient billing consultants face the daily challenge of receiving the maximum appropriate reimbursement for services provided. Their job is to process, submit and follow up on claims to both private insurance companies as well as the government – Medicare and Medicaid.
This is a simplistic overview of what is in reality a very, very complicated process.
Let’s assume for a moment that there was no narrative – that Mrs. Smith saw her physician for a sore throat. As it happens while she was speaking with her physician, she mentioned that she was also having some arthritic pain in her right shoulder and left knee, which was sort of difficult for her to describe. In addition, she mentioned that the mild depression she’d been feeling in the past, which had been previously discussed, was much better since she started walking two miles a day.
Now tell me, how is an EMR going to capture that? If I were Mrs. Smith, it would be important to me that those things which I shared with my physician were being captured somewhere and not simply left out because either the EMR was not able to capture it or perhaps if the physician was doing his own front-end speech, was left out because now we’re talking about a much longer narrative and therefore a much longer process for the physician.
Dictation that is transcribed or edited quickly and accurately is a critical piece of the patient documentation process and thereby improves the appropriate reimbursement.
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