Are you in the process of converting to a therapy electronic medical record (EMR)? Or perhaps you are still considering which EMR program you will select? Regardless of where you are in the process, you will need these three tips when converting to a therapy EMR. But first, before I share three tips when converting to a therapy EMR, let’s get some context and background.Therapy practices are rapidly converting to EMRs, if nothing else to help them keep up with the Medicare documentation, coding and billing requirements. If PQRS has not been implemented this year at your private practice in enough time to capture minimum measures on at least 50% of Medicare patients, 2016 Medicare revenues will be reduced by 2%. The non-payable functional limitation reporting codes (I repeat – non-payable) will cause you not to be paid if they are not coded and billed properly. Oh, did I mention if CMS has hard edit problems (common working file) or soft edit problems with the various MACs, you have a risk of having a non-payable code cause a non-payment (isn’t that an oxymoron?). Have I got your attention? These two factors are at the top of the list for therapy practices looking to rapidly convert to an EMR. And these are very good reasons.
Three Tips When Converting to A Therapy EMR – They Are All Common Sense!
Much of therapy documentation is compliance, and a much of compliance oversight is ensuring that documentation and coding meets Medicare requirements. So this will make perfect sense as my top three tips when converting to a therapy EMR.
- Know Medicare documentation requirements. There have been sequential therapy documentation updates for the past nine years, yet many providers still do not know basic requirements for each therapy note, for recording minutes properly and timeframes for certification of the Plan of Care, just to name a few. Documentation requirements are found in the Medicare Benefits Policy Manual, Chapter 15, beginning at Section 220. If this is too much to read, there are documentation courses that focus on the key elements of therapy documentation, and additional courses that focus on coding and specialty services including wound care, skilled maintenance therapy, and the like. Secret: coming soon all the basic courses and more – let me know if you are interested.
- Understand the Local Coverage Determination (LCD) for your Medicare Administrative Contractor (MAC). CMS has allowed the MACs to define certain items under “local decision” through a formal process of development, review and approval of a local coverage determination. NGS provides great detail on what they expect to see as best practice documentation for each CPT© code, and includes required documentation for the 10 visit marks. Whereas other contractors may not offer that level of specificity. Look for services that aren’t covered by all MACs: mist therapy and ionto come to mind! Some MACs don’t have a policy for Part B, but if you ask, they likely will tell you to follow the policy for Part A (Rehab Agencies, CORFs and Hospital OP departments). Bottom line: if your MAC reviews your records, you will be reviewed against their published requirements.
- Get a “visual” on what each therapy note should look like at “best practice”. Remember the old CMS 700/701 forms? (maybe you would rather forget), but it provides a visual on how a form is organized to showcase required plan of care elements (prior to functional limitation reporting). For APTA members there are a series of samples and check lists available in their Defensible Documentation series (available at the APTA website). Your MAC may also have posted samples of best practice documentation. Alternatively have documentation on your current forms reviewed by a documentation or therapy compliance expert. If you have no idea what best practice documentation looks like prior to starting in an EMR, it will be more difficult to “see” as you are entering data in the EMR database “boxes”.
There it is! Pretty easy, right? Let me know what you think!