Consult #9 EMR Macros and Reporting
Sending Your Reports
We have talked at length about the importance of reporting. Reporting is used for not only billing and collections, it is used for compliance and marketing as well. You would spend hours and hours creating the perfect ad for the yellow pages or your local newspaper, yet we completely overlook the importance of our documentation. With the advent of EMR, the customization portion of documentation can be overwhelming since there are so many ways to customize. Here are a few points to focus on to make it more fun and actually be something that you are excited to do and proud to display.
1: Reports formats must follow CPT Guidelines for the level of service that you are providing. This is for Evaluations and Re-evaluations most particularly. Your daily notes are in SOAP format. SOAP format is NOT adequate for Evaluations and Re-evaluations, these needs to follow E/M coding guidelines.
2: Fax do not mail. The sheer volume of reporting in today’s healthcare environment necessitates lower costs and increasing output. NEVER mail your reports, FAX ONLY. This is a very efficient method to deliver your reports to primary care doctors, medical specialists, lawyers and the insurance carriers. One printed report can be sent to all of the above mentioned professionals instantly through the fax machine with a confirmed delivery.
3: The cover sheet can actually be a fax cover sheet. That is what I do at my office and it makes the process flow a lot smoother. When the report prints, it is ready to go. The first page in the EMR template is the fax coversheet.
4: Carbon Copy – the CC at the end of the report indicates who get a copy. The fax coversheet and therefore the report is presented to the referring doctor OR the primary care doctor if there was no referral. The rest of the patient’s doctors and or attorney get a carbon copy or CC. So as an example if I were sending to Dr. John Smith (the patient’s primary care doctor), Dr. Mike Jones (neurosurgeon), Allstate Insurance, Mr. Donald McRonald (attorney) and Dr. Pain Management it would look like this at the end of the report.
William J Owens Jr DC DAAMLP CCP
Cc: Mike Jones MD
Donald McDonald MD
Pain Management MD
Now my staff understands who gets the report via fax, we have all the numbers EXCEPT THE CARRIER in the fax on autodial. The carrier will get the report with the billing.
5: Compliance and Audits – when you send your reporting with your billing there is little for the carrier to “review” or audit. It is all there up front and you have justified your care. Very simple and effective. There is nothing else that you are going to need to say as long as your documentation meets the level of our coding. Simple.
6: Credentials – if you have special teaching positions or additional board certifications you MUST include these on the fax coversheet or the letterhead of your report. These types of credentials need to be FRONT AND CENTER for the world to see. This does not take the place of your CV, but it puts your additional expertise out there. The most important are teaching positions or addtional Board Certifications, do not put TECHNIQUE certifications there, the medical community does not care.