By: Ronda Ash, CPC, CPMA, CHC, CHCA, CIFHA and Joe Laden
The benefits of your anesthesia care being documented electronically are numerous including consistent and legible documentation. However, a well thought out anesthesia information management system (AIMS) has other benefits in our data driven practice environment. In the current landscape having a mechanism that allows for fast, efficient, consistent and legible documentation can support many of your practice initiatives. Collection of data for the Merit-based Incentive Payment System (MIPS), quality improvement, risk management, clinical research, billing and compliance are among the most prominent reasons for adopting an AIMS system.
System changes within the hospital(s) are also a big driver for adopting an AIMS system to replace the paper and adjusting the overall flow of information within the facility for efficiency reasons. Often within hospital systems, anesthesia is the last department to be launched onto the electronic medical record (EMR). This process can be time consuming and detailed but there are a few things that your practice can do to make this transition smoother.
It is paramount that you appoint a liaison for your group to make sure the clinical information is complete and pertinent. Things like order sets, agents and drugs utilized, equipment used are all areas that will need to be detailed and reflect what happens in your organization. If this step is overlooked, you may end up with what the IT department thinks you do.
Getting this information correct at the outset of implementation can help shore up the revenue that may be at risk through the transition due to cash flow challenges or not being able to bill properly because data elements were missed. Working with your hospital partner to send all the required information to your billing system, or vendor, for meeting the information needs of the payment team and fulfilling the Centers for Medicare & Medicaid Services (CMS) MIPS submission requirements will be a priority during this time.
This is an area where a checklist could be a powerful tool to insure a smooth transition from paper to an EMR. As you develop one, consider including not only clinical elements but also those that are used for payment purposes. For example, if the EMR includes information that will support the medical necessity of anesthesia care, the time it takes to submit a claim may be reduced, and you could facilitate more prompt processing and payment from the payer.
A well-planned transition that includes all necessary information transferred electronically to the billing system will eliminate data entry errors, reduce processing time for your claims, and provide the coding staff with the data they need to properly report the services provided.