It is the responsibility of each provider to document care in the progress note to support all services that were provided to the patient. If the service was provided but was not documented in clinical record then technically the service was not provided. During an audit the insurance carrier has the right to request a refund for all services not supported in the clinical record. To ensure all charges are supported by the clinical document, healthcare providers must utilize EHR technology that allows them to document care “real time” during each patient visit. Having the EHR software drive the CPT / charges to the practice management software ensures the practice remains in compliance with their billing.
MD Logic, the leading U.S. provider of high performance electronic health records solutions, gives physicians the technology they need to quickly document care and ensures that all services provided are supported by the clinical record. As services are provided and documented in the MD Logic EHR during the patient visit, those CPT and diagnosis codes are automatically updated in the practice management software and ready for insurance and patient billing. Utilizing the MD Logic EHR software eliminates the risk of charging for services not documented in the clinical record. At the same time the practice eliminates those common missed charges that were never checked off on the paper charge ticket.
If your clinic is still using paper charge tickets then it is time to learn how your clinic can increase efficiency, reduce overhead and maximize profitability with MD Logic.
To learn more please contact our corporate office at 800-273-7750.