Electronic Health Record (EHR) and Practice Management (PM) systems bring greater efficiency to the medical billing process.  Small private practices using EHR software find that their billing processes have been stream lined because procedure and diagnosis codes are automatically created and assigned making it easier to create superbills. However, most of auto generated codes still requires a skilled medical coder to review to ensure that submitted medical claims are compliant with CMS and private payer guidelines.

One of the software used to generate auto codes is Computer Assisted Coding (CAC), which uses SNOMED CT (Systematized Nomenclature of Medicine–Clinical Terms) concepts and terminology to assign CPT, HCPCS Level II, and ICD-9-CM codes based on the contents of the EHR.  However, coding software can generate code sets that are considered mutually exclusive or medically unlikely according to third-party payers.  Therefore, EHR/PM generated codes require thorough review by a professional medical biller or a medical coder who is experienced in current coding requirements, such as the quarterly updated National Correct Coding Initiative (NCCI).

Procedure codes can bypass NCCI edits through the judicious use of modifiers.  When an individual code or a set of codes is flagged for NCCI compliance, a professional coder reviews the documentation in the EHR to determine 1) if a modifier is appropriate, and 2) which modifier most accurately reflects the circumstances under which the service was provided.  

EHR does not use Modifiers appropriately 

Modifiers should never be applied automatically.  The medical record needs to justify the modifier’s use.  While some of the information contained in a medical claim can now be generated without human intervention, an accurate medical claim is created through informed translation from the language of medicine into the language of industry standard code.  When modifiers are reported routinely, without reference to the available documentation, this exposes a physician practice to charges of fraudulent or abusive billing practices.

Modifier -25 has always been a particular concern to Medicare and other payers.  This modifier is applied to E/M services that are separate and distinct from procedures that occur during the same encounter.  When a patient receives and injection during an office visit, the code for the procedure takes precedence since evaluation and management is implicit in the CPT code 96372.  The experience of a medical coder is required to review the medical record to guarantee that the use of modifier -25 is appropriate for the healthcare claim that includes both 99213 and 96372.  After that, the codes are forwarded to a medical biller to submit a completely compliant, clean claim.

EHR and Professional Coder role in Audits

Audits are designed to detect abusive billing practices by selecting a wide range of claims. Medical practices are targeted by Recovery Audit Contractors (RACs) that they feel are susceptible to abuse. 

In any payer-initiated audit, comprehensive documentation is the key to avoiding penalties and revoked payments.  Prior to the advent of EHR and CAC and other related softwares, medical coders were not expected to review the majority of medical claims.  These claims were coded by hand and a measure of professional oversight was presumed.  With the advent of CAC, and increasingly frequent audits, the direct intervention of medical coding professionals is more frequent in order to guarantee that the codes assigned match the EHR.

The best way to guarantee easily passing an audit is to employ a professional medical coder to review claims before they are submitted.  While negative audit results can be appealed, these are time-consuming and costly.  It is far better to take proactive steps by employing a professional coder to review questionable claims and modifier usage.  

Best Practice is to use EHR with professional Coder and Biller

A medical coder ensures a higher standard of compliance to government healthcare program and commercial insurance requirements.  Medical coders look into EHR and read thru the available documentation to justify the codes assigned to medical conditions and procedures. Where as professional medical biller is trained to assemble clean medical claims for prompt reimbursement.  A biller also posts payments, reconciles accounts, and answers patients’ financial questions. 

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