New Billing Feature In Patch 12

Day-to-Day Users
1

fsgl wrote on Friday, March 29, 2013:

Billing now includes a feature listing all encounters that are without a charge.  There are no selection boxes next to each the encounters in this listing, thereby distinquishing them from encounters which have charges and  need to be billed.

In our office we don’t charge for pre and post op visits and for such visits as checking of glasses.  This new feature was probably added to help those offices that forget to use the fee sheet for a visit that requires one, but our office does not need this refinement.

Is there a way to turn off this feature without getting into the codes?

2

sunsetsystems wrote on Friday, March 29, 2013:

If I recall correctly, you can put in any billing code (perhaps invent one for the purpose) and then you should be able to mark the encounter as cleared.  No charge required, but you do need a billing table entry.

Rod
www.sunsetsystems.com

3

mdsupport wrote on Saturday, March 30, 2013:

Our practices have added ‘dummy’ CPT4 code GRATIS with service charge 0.  This has allowed us to :
1. Follow standard billing review/approval process steps
2. Allows staff to record the encounter without the billing implications
3. List/analyze historical information on free visits
4. Handle situations where multiple encounters were created in error and could not be merged.  Only one was billed to insurance.

4

fsgl wrote on Saturday, March 30, 2013:

Thanks for the quick responses.

I had a similar situation with the PQRI codes.  I hoping to save myself a little time by assigning a zero charge to each of the codes to avoid more work with adjusting out a penny charge.  The Fee Sheet just sat there and could not be coaxed out of recalcitrance until the penny was put back in under Services.

Just tried Rod’s suggestion and the Fee Sheet behaved in the same fashion with a zero charge.  Additionally the selection box won’t pop up for the encounter to be cleared if there is not at least a penny assigned to the internal CPT code of 00004.
The penny charge then has to be deleted from the Billing View of Past Encounters & Documents.  I also have to add a billing note as to the reason why I charged the penny because several months from now I won’t remember.

The list of no charges in Billing is rather innocuous but if I cannot live with it, a few contortions as previously suggested will clear the lot of them.  I can always write the note by hand avoiding OpenEMR for all future no charges. If this new feature helps colleagues gather up all the encounters that should be billed, whining would not be appropriate.

5

fsgl wrote on Friday, April 26, 2013:

One problem with using an encounter with no charges arises with Meaningful Use Attestation, specifically the Core Measure of providing Clinical Summaries. If a no charge encounter is generated, that encounter will add to the denominator for that measure. If no Clinical Summary is provided for that visit, the overall ratio is pulled down. This becomes crucial if the threshold is hovering around 50%. It makes for non-productive work for the staff to provide a Clinical Summary if the visit is free, merely to satisfy a bureaucratic dictate.

As a result, phone conversation documentation and freebie visits such as post-operative visits and glasses checks are placed elsewhere, to avoid distorting the calculation for that Core Measure.

6

yehster wrote on Friday, April 26, 2013:

A customization to checkEncounter function in library/ClinicalTypes/Helper.php to filter out encounters based on billing criteria (either no charges, or only your “internal codes”) is probably the best way to address this in your practice.

However I’m not sure it would be appropriate to exclude post-op checks even though it’s a “freebie” as there is still a care plan to be summarized:

e.g. post phaco/IOL “keep using Vigamox for a couple more days, come back in a month for a refraction to see how well our fancy gizmos chose the IOL and if you are going to want glasses for distance, near vision or both(yuck).”

7

yehster wrote on Friday, April 26, 2013:

Also I think the problem of phone conversations with an encounter counting against you in the numerator for AMC is/was an issue before the Billing Feature was implemented.

However, I agree that this change

Should probably be configurable. It’s clearly useful for the report to work both ways.

8

fsgl wrote on Friday, April 26, 2013:

Hi Kevin,

I am not suggesting zero documentation of post-operative visits. That would be tantamount to putting a sign on one’s back, “Sue me. Bring it on!”. Our medical liability mutual company stresses repeatedly that good medical records are a physician’s best defense. Even your first year medical student would know that no documentation is a very dumb idea. (Is “yuck” a new descriptor in SNOMED or is it a reaction to Presbyopia?)

I prefer to use an old technology, pen and paper; scan the “freebie” notes and put them into Documents-> Medical Record. I have used the Disclosures module for documentation of phone conversations as well. Patch 12 brings in phone conversation encounters and distorts AMC tracking, thus they must be squirreled away in Disclosures. The Messages module does not serve very well.

The git.hub link might as well be in Aramaic. Yours truly is totally illiterate in “Geekian”. The “Medicalese” is good enough for government work.

9

mdsupport wrote on Friday, April 26, 2013:

We are struggling with AMC vs proper documentation. Some sample problems -

  1. Pt is checked in, vitals recorded and then leaves w/o being seen by a physician.
  2. Management of chronic conditions is billed on a monthly basis based on amount of time spent during that month - including ‘remote’ encounters. So it makes sense to record phone conversations as encounters but not all are billed immediately.
  3. Pt is seen in the office, sent to a facility and then admitted there on the same day. Only facility encounter is billed.

Since attestation gives some leeway to the reporting entity about encounters, does it make sense to put a box on the encounter form as “Not AMC encounter” and exclude it from AMC denominator computation?

10

yehster wrote on Friday, April 26, 2013:

I was pretty sure you were doing something, but not enough to meet the MU criteria.
I am realizing that the rules for MU may allow you to treat post-op visits either way at your discretion w.r.t to the goals. (ou understand the MU rules/exceptions better than I do.

Regardless, even before this change went into billing, in general the ruleset definitions count ALL encounters regardless of the presence or absence of fee sheet entries.

In other words your “quick and dirty” documentation for your easy freebies was already counting against you for MU. If you don’t want them to count in the denominator, code somewhere will have to change.

The “yuck” was for an extreme hypothetical scenario where the measurements taken by the “gizmo” were so bad that the selected IOL is several diopters away from the ideal that the patient requires multifocal glasses, but really I was just trying to show off my jargon.

11

fsgl wrote on Friday, April 26, 2013:

Kevin,

Diopters? Someone must have done a rotation through Ophthalmology. You must excuse my “yuck” remarks. Old folks like to tease young folks.

The way CMS has structured the attestation, asking about whether the data is drawn from the EHR alone or EHR plus paper records, suggests that they don’t expect us to have everything in electronic form; therefore, by inference, I should be able to document on paper as well.

You do bring up a good point about the possibility that concurrent paper documentation may not be CMS “orthopraxy”, but there is nothing at their website which states no paper notes whatsoever. I don’t make a habit of reading the Federal Register. (As Mr. Carson remarked: “I’d sooner chew broken glass.”) If you come across a pertinent section in the Federal Register, or elsewhere, please share it with us.

This would be a rather unreasonable demand on their part. I am sure all the seniors would be up in arms, if we had to convert 30 plus years of paper records into a purely digital form. If the Feds were to dictate that I must document patient visits with the Encounter module exclusively and not in Documents->Medical Record, that degree of specificity would make their guidelines so complex; effectively rendering compliance unworkable.

If the new encounter link is not clicked and the paper note is scanned into OpenEMR, it is not tracked in the AMC report. This has been verified after running several AMC reports and checking the numbers.

MD Support,

  1. If the patient leaves prematurely, it would be helpful to have a way to record the Vital Signs without generating an encounter, if the practice does not want to charge for it. The Notes module is for notation relating to the practice and not specifically for the individual patient, so it is not particularly useful. Something along the structure of the Disclosures module would serve well.

If a practice charges for telephone management, then an encounter should be generated. At least you are permitted to supply just 1 Clinical Summary for the collection of phone encounters (per the last FAQ of the attachment below), making life easier for the staff.
3. If a patient is seen before being sent to the ER or to the floors, the office visit should be billable. It is less annoying to provide the Clinical Summary if the practice will be compensated for the visit. No one likes an unfunded mandate.

Developers would need to decide if it’s practical to have that special box to exclude the visit from AMC tracking. More importantly you would also have to decide if it complies with CMS’ guidelines for Meaningful Use. I don’t know the answer to these questions. The Specification Sheet for that Core Measure, that I have attached, does not give enough guidance.

As for myself, it is much less work overall to avoid the new encounter link for the freebies; otherwise there will be a bit of fussing about in the Billing module to get rid of them and more fooling around to prevent them from messing up the AMC.

12

fsgl wrote on Saturday, April 27, 2013:

MD Support,

I’ve located another resource to answer your first concern. See the first “Lessons from the Field”, at this link. This de facto understanding of this particular measure would be interpreted thus: The Vital Signs recorded by staff can be reviewed by the physician (which (s)he would do anyway); thereby relieving the physician the obligation of actually seeing the patient under this unusual circumstance.

I completely forgot that there is a Vitals module for Vital Signs and weight because it was disabled in our practice. Staff can then start a new encounter with a notation that the patient left too soon, click the Clinical Summary box and you will get the credit for this measure. But you’re still left with the other part of the requirement to send a Clinical Summary to that patient. Nevertheless,it is still good to know that you are in compliance.

The website cited above is geared more for developers. If you find anything more informative there, please share.