How Does a General Surgery EHR Differ from a Generic EHR System?
Currently, approximately 96% of hospitals in the United States utilize an Electronic Health Record (EHR) system; however, nearly half of surgical specialists continue to rely on generic systems. This leads to slower documentation processes, an increase in the number of clicks required, and the omission of crucial details essential for surgical care. Research indicates that transitioning from a generic EHR to a platform specifically designed for surgery can enhance documentation efficiency from 6.02 to 7.20 on a scale of 10. This transition results in more precise records, improved claim tracking, and enhanced workflow support. But what precisely distinguishes a general surgery EHR from a generic one? Why is this distinction significant for surgeons, patients, and hospitals? Let us begin with the fundamentals. What Distinguishes General Surgery EHR from Generic EHRs? Not all EHR systems are created equal. A general surgery EHR is specifically tailored for the workflows associated with surgical billing systems, whereas a generic EHR offers only broad, standard functionalities. A general surgery EHR encompasses templates for pre-operative and post-operative procedures, along with tools for creating operative notes. It also features surgical scheduling capabilities and coding tools specific to surgery. In contrast, a generic EHR provides basic functionalities such as charting, scheduling, and lab orders. However, surgeons frequently require customization, which can hinder efficiency and increase the likelihood of billing errors. Comparison of General Surgery EHR and Generic EHR General Surgery HER Generic EHR Templates for Pre-op, intra-op, and post-op Basic charting templates OR block scheduling and surgical calendars Standard patient scheduling CPT, ICD-10, and modifiers tailored for surgery General coding support Auto-populated operative notes Manual or limited note fields Tracks global periods and compliance Limited compliance features Reduces denials, maximizes revenue. Higher risk of errors and lost revenue What is a General Surgery EHR? A general surgery electronic health record (EHR) denotes a digital record system tailored specifically for surgical practices. It aligns with the workflow of surgeons, resulting in more precise documentation, easier compliance, and the ability for practices to secure full reimbursement. What is a Generic EHR? A Generic EHR is a flexible electronic health record system designed to serve multiple specialties. It provides fundamental EHR functionalities. While a generic EHR is effective for routine care, it typically lacks surgical templates and billing tools. Workflow in General Surgery EHR vs. Generic EHR General Surgery EHR Workflow An EHR tailored for the surgery streamlines the entire process. Pre-operative procedures begin with integrated templates. Operating room time is scheduled directly within the system, eliminating unnecessary back-and-forth communication. Subsequently, it applies the appropriate CPT codes and modifiers according to U.S. regulations to mitigate billing errors. Follow-up appointments are linked to the same episode of care, ensuring that nothing is overlooked. Generic EHR Workflow In contrast, a generic EHR requires more effort for every task. Pre-operative and post-operative notes must be created from scratch or extensively modified. Operating room scheduling occurs outside the system, leading to delays and miscommunication. Operative notes are entered manually, increasing the likelihood of omitting important details. Billing necessitates a review of codes and modifiers due to the absence of surgery-specific prompts. Additionally, follow-up appointments are monitored as standard office visits, resulting in compliance issues and slower reimbursement. Step in Workflow General Surgery EHR Generic EHR Pre-Op Prep Integrated surgical templates Custom notes created manually. OR Scheduling Direct operating room block scheduling Managed externally or with additional tools Operative Notes Auto-filled procedure fields Manual, labor-intensive entry Billing & Coding Surgery-specific CPT, modifiers, and global period tracking General coding: high risk of errors Post-Op & Follow-Up Bundled care is automatically tracked Handled as regular visits; risk of missed compliance. Differences Between General Surgery EHR Billing and Generic EHR General Surgery EHR Billing Specialty coding: Incorporates built-in CPT and ICD-10 codes specifically for surgical procedures. Modifier support: Automatically applies the appropriate surgical modifiers. Global period tracking: Monitors bundled pre-, intra-, and post-operative periods to prevent double-billing. Op note integration: Extracts billing codes directly from the operative note. Fewer denials: Surgery-specific validations minimize coding errors and denials. General surgery billing software leads to expedited claim submissions, cleaner claims, reduced denials, and enhanced reimbursement accuracy. Generic EHR Billing Basic Coding Support: Manages general CPT/ICD-10 codes but lacks the specificity required for surgical procedures. Limited Modifier Use: Modifiers often need to be manually added by coders or billers. No Global Period Tracking: Considers follow-up visits as separate appointments, which may lead to compliance issues and denials. Manual Data Entry: Operative details do not automatically link to billing; coders are required to manually extract the information. Higher Denial Rates: Increased errors and missed charges arise from the absence of specialty-specific checks. In comparison to general surgery medical billing software, generic billing necessitates more manual effort, results in higher denial rates, prolongs the revenue cycle, and increases the risk of underpayment for surgical practices. What are the Advantages and Disadvantages of General Surgery EHR and Generic EHR? General Surgery EHR Advantages Disadvantages Templates tailored to the specialty Higher expenses in comparison to general EHRs Management of OR block scheduling and surgical workflows May necessitate additional training for staff to utilize advanced functionalities Integrated surgical coding support (CPT, ICD-10, modifiers, global periods) Demands extensive staff training Enhances billing precision and decreases claim denials Excessive dependence on EHRs Boosts compliance with specialty-specific regulations The implementation process is prolonged. Generic EHR Advantages Disadvantages Lower initial costs compared to specialty EHRs Lacks templates and workflows specific
CPT MODIFIERS IN BILLING AND CODING
The CPT modifier (Current Procedural Terminology) consists of a two-digit code predominantly utilized in medical billing and coding practices. It serves to convey details about the medical procedures or services that healthcare providers offer to their patients. The two-digit CPT code elucidates specific treatments, variations, or circumstances involved in the care provided. CPT modifiers enhance the clarity by offering additional insights or descriptions related to the physician’s services. These modifiers distinctly articulate the medical procedure by altering its definition. This article will illuminate some of the frequently utilized CPT modifiers in medical billing, along with their interpretations. CPT Modifier 25: This modifier applies to the evaluation and management of services or procedures that the same healthcare provider provides to the patient on the same day as another professional introduces a new service or procedure. The patient can receive the services and procedures outlined by this code, necessitating further evaluation and management beyond the usual preoperative or postoperative care. This evaluation and management are driven by the patient’s condition, and it mandates reimbursement for both the procedure and the evaluation and management (E/M) components. CPT Modifier 50: This modifier signals the execution of additional procedures on both sides of the body during the same operative session. It is relevant for procedures performed symmetrically on body parts such as the eyes and knees. CPT Modifier 51: Modifier 51 indicates that two or more procedures are performed simultaneously in the same operative session. It signifies that the payer is required to provide additional reimbursement for the new procedure in the medical billing process. CPT Modifier 58: This modifier is employed for pre-arranged and documented therapy received by a patient following a major surgery. The surgical modifier 58 within medical billing is recognized as a new procedure, necessitating reimbursement for subsequent medical procedures during the postoperative period. CPT Modifier 59: Modifier 59 is used when multiple procedures are performed on the same patient on the same day, but they are not bundled together. It indicates that separate reimbursement should be provided for additional procedures in medical billing. These procedures are unrelated and may require different physicians to execute them in conjunction with the same organ or system on the same or different days. Consequently, reimbursement in medical billing is contingent on the sub-surgical CPT modifier. CPT Modifier 76: This modifier is relevant for the repetition of medical procedures on the same day due to specific medical conditions. It signifies that services or medical procedures should be repeated on the same day after the original procedure. Modifier 76 clearly distinguishes between repeated and duplicate services. CPT Modifier 78: This modifier indicates unplanned postoperative procedures, signifying the unexpected return of a patient to the operating room or procedural space immediately following the original treatment. It reflects unforeseen outcomes of earlier surgery, such as infections, hemorrhage, or debridement, which necessitate the urgent return of the patient. Importantly, the second procedure must be directly related to the initial medical procedure. Moreover, surgical modifier 78 is not exclusively for addressing complications, but also for managing all aspects of postoperative care. CPT Modifier 79: This modifier is applied when patients return to the same healthcare provider during the postoperative period to receive unrelated medical services. It involves performing different procedures or services on the same anatomical location by the healthcare provider during this time. Conclusion The article has touched on several examples of CPT modifiers. A variety of CPT modifiers exist to communicate specific information relevant to the service period. It is essential to refer to the official guidelines of CPT coding to ensure that payers can adequately compensate for the precise services coded for billing purposes. Accurate medical billing with the correct modifiers results in fewer claim denials and ultimately enhances reimbursement rates. This assists healthcare professionals in conserving funds for medical establishments.
Confused About PHR, EMR and EHR? Here’s What They Are and How They Differ
When the movement to digitize medical records began, the new terminology was not very clear, and electronic medical records (EMR) and electronic health records (EHR) were often referred to as EHR/EMR, so it is no wonder that people were confused about the terminology. Adding to the confusion, the two terms were often used interchangeably by people who did not know the difference or who thought it would be easier to use only one term. With the introduction of electronic systems and the addition of personal health records (PHRs), it is time for all of us to clarify what these various records are and how they are used. Electronic Medical Records – Patient Records on a Computer The simplest way to describe electronic medical records is that they are electronic medical records or digital medical records. EMR refers to the records or charts of individual patients, including notes on diagnoses and treatments, maintained by each facility. When you consider how easy it is to access information in digital form, the benefits of EMRs over paper records become very clear. Practices can easily send reminders for routine and preventive checkups. EMRs also allow doctors to view a patient’s medical history and track changes over time, which is very difficult when all the information is on different pages in a folder full of different reports. These combined benefits empower healthcare providers to deliver quality care overall. Electronic Health Records – Patients Networking Service Providers Traditionally, specialists have been very limited in their access to information from general practitioners and vice versa. Similarly, specialists at different facilities could not easily review a patient’s medical history from another healthcare provider. This could mean that highly relevant information is missing in medical decisions, such as when a cardiac patient suffers a stroke or a diabetic patient is involved in a car accident. Having full access to a person’s medications, medical history, and expected condition can be extremely helpful in diagnosis and treatment. Laboratories, hospitals, and specialists can all access this much-needed information. If a patient relocates to another city or state, new doctors and other health care providers can access the patient’s medical history through the electronic medical record, so important information isn’t lost every time a doctor changes. Personal Health Records – Patient Involvement in Their Own Care The same type of information found in electronic health records is also included in personal health records, but they are designed to be managed by the patient, who can access and enter their own records. Personal health records include diagnoses and medications, but also store family medical history and immunization records. PHRs allow patients to update and access their information from the comfort of their own home. PHRs can be linked to EHRs, eliminating the need for patients to add all of the information themselves, resulting in a more complete record. EMR/EHR Caveats Electronic health records (EHRs) and electronic medical records (EMRs) often come with software that will “advise” you on coding. This consulting software is touted as helping you take your CPT to the next level if you document more, leading to increased revenue. Fully documenting can turn a level 3 visit into a level 4 or even level 5 visit. Level 4 and 5 claims are easily spotted and challenged. Don’t think that automated code advisors with electronic medical record software have solved these problems. Somewhere in the software documentation, there will be a disclaimer explaining that the code consultant only determines and provides advice on the appropriateness of coding, and that responsibility for the actual coding remains with the physician. Also look at the diagnosis. The level of service provided must also correspond to the diagnosis being treated. The level of care requirements may all be well documented, but are the diagnoses being treated commensurate with the level of service? Increasingly, payers are using computer-based models to compare CPT codes to diagnosis codes and identify patterns of what may be considered overpayment for listed diagnoses. For example, it would be difficult to justify an ear infection in an otherwise healthy patient with stage 5 E/M, even if the stage 5 was fully documented per documentation standards. MedEx MBS offers a full range of healthcare revenue cycle management (RCM) services for healthcare providers of all sizes. Our innovative medical billing and practice management systems are proven to increase revenue and reduce stress for your customers. request a demo to discuss how we can help you achieve your business goals.