EMR/EHR Coding : What you need to know?

EMR coding

It comes as no surprise that the medical industry is becoming digitized with every passing day. Thanks to all the new CPT updates, ICD codes, and other coding trends that are making a way to revolutionize the entire realm. EMR/EHR coding has also transformed the way patients records are collected, recorded, and processed.

When it comes to EMR/EHR coding, the size of the entire market will grow at a CAGR of 10.9% and increase from USD 70 billion to USD 120 billion, by the end of 2023. As a part of Health HITECT Act of 2009, the federal government has also allocated $25.9 billion for encouraging the certified providers.

Considering these statistics, you should not be holding back from adopting EMR/EHR coding system at your facility.

Don’t know where to start? Read all the essential details in this post.

Appropriate Standards and Protocols

Some of the must follow protocols for an EMR/EHR Coding system include Current Procedural Terminology (CPT) codes, ICD-9/ICD-10 codes, and the Health and Care Professionals Council (HCPC) standards.

Make sure you leverage electronic medical and health records in compliance with all the industry’s regulations.

EMR coding

Must-Have Smooth Interface and Integrations

While you plan to implement Electronic Medical Records solution, consider the two most common points of integration including-

  • Billing System: The billing system integration is essential for improving the efficiency of the front desk’s staff and offering better patient services. As you will add the patient files in the system, the data will be matched, and your billing process will streamline automatically.

With this integration, you will have more time on patient care rather than spending it on operational processes.

  • Hospital Information System (HIS): This information system comes to your rescue if your practice is a part of large institutional networks.
  • Have a Patient and Medical History Page: The patient page contains an individual’s data, including age name, gender, current medications, allergies, and other data that gives an overview of one’s health. On the other hand, the medical history keeps track of patient’s medical history, such as illnesses, treatments, contradictions.

Both of these features allow the patient diagnosis on time and keeps you updated on the patient’s health progress.

EHR Coding

Charting

I prefer to file charts, said no doctor ever.

If you also make charts from home, stay after your shifts, or come on off days to complete your documentation, it’s time to level up your EMR system. Implement features such as dictation functionality, customizable chart templates, machine learning, or voice recognition.

The customizable chart templates let you adjust the charts and configure them, according to your practice. Machine learning makes the software learn standard information that will make your process effective with auto-prompts, and more.

Should Have Medication and E-Prescription Tracking

The EMR coding solution should track all the prescribed medications, and have the information at disposal, irrespective of the scenario. You can also consider getting extra functionality to check, how prescribed medication interacts with the current medicines that are taken by the patient.

Along with this, your EMR/EHR coding system can have a cloud hosting, dedicated patient portal, appointment reminders, integration with lab, and more. It should be HIPAA compliant and follow all the management and evaluation of documentation standards.

EMR/EHR Coding Benefits

  • Both electronic medical and health records add flexibility to the task of coding, allowing coders to read digital documents directly, and then solving issues with legibility.
  • Allows seamless data transfers between various departments.
  • Reduced operational expenses such as medical transcription services.
  • A lot of physical space is saved at your practice.
  • Coders can access their work remotely with EMR/EHR. On the other hand, the paper-based coders have to wait for records to be picked and assembled.
  • Makes a collaborative environment for managing sensitive patients’ data.

The EMR/EHR software leads to a reduction in billing and coding errors, keeps the data organized and benefits both patient and doctor.

Whether you are planning to code using EMR/EHR or have already started to implement it, we hope that the above guide comes to your help. You can also turn to GreenBills, which is the first EMR/EHR designed for PIP, no-fault, and workers compensation medical providers. It a web-based practice management software (HIPAA-compliant) that eliminates paper sign-in sheets handles a large volume of cases and allows you to focus on your practice.

For more details on our medical billing and coding services, you can send us your queries at hello@getgreenbills.com or call at 646-904-8805.

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