ICD-10 / The End of Paper Superbill

Even with all the latest healthcare technology on the market, the vast majority of healthcare providers still use paper charge tickets/superbills to check-off the services provided for each patient visit. At the same time these paper charge tickets/superbills have the most common ICD-9/Diagnosis codes utilized by the clinic. The physician, PA, NP or PT use the paper charge tickets/superbills to report the charges and diagnosis to the front desk. Beginning October 1, 2015 these healthcare providers will be in for a rude awakening – ICD-10 Codes.

Due to time restraints and a market littered with non-productive EHR technology, utilizing paper charge tickets/superbills is the preferred method of capturing charges and diagnosis codes for healthcare providers. These paper charge tickets/superbills create an insurance audit liability since there is no confirmation between the CPT/Diagnosis checked and the clinical record. There is no guarantee the physician, PA, NP or PT will remember to go back and add the clinical data in the electronic health record to support the paper charge ticket/superbill. To ensure coding and billing compliance, both the CPT and Diagnosis codes should be generated from the clinical documentation – not vice-versa. If the clinical record does not support the charges/diagnosis codes during a 3rd party insurance audit then the services were considered never provided in the eyes of the insurance company. A random audit with a 20% failure rate for unsupported charges allows insurance companies to request a 12-24 month pay back from the clinic based upon the carrier. Not having your EHR drive the charges and diagnosis codes is simply a liability for any clinic or provider.

Another problem moving forward with paper charge tickets/superbills is the growing number of ICD-10 codes. With the massive increase in the number of diagnosis codes (ICD-10) beginning October 1, 2015, clinics that utilize paper charge tickets/superbills will be forced to print a paper charge ticket/superbill that may be 3-4 pages to include all the new common ICD-10 codes. Generating this much paper goes against everything EHR technology is all about.

As the leader in high performance electronic health records solutions, MD Logic provides physicians, PAs, NPs or PTs with the technology to document care real time in the exam room. The clinical documentation generated by MD Logic creates the CPT/Diagnosis codes that are automatically updated in the Practice Management software and available for insurance and patient billing. No need for a paper charge ticket/superbill with MD Logic.

Tim McKenna, Vice President of Sales for MD Logic, stated “MD Logic is the only EHR capable of keeping pace with a busy clinic in terms of real-time documentation. By documenting real-time in the exam room our customers are 100% guaranteed the charges and diagnosis billed to 3rd party insurance companies are supported in the patient’s health record. Busy clinics are targeted for insurance audits all the time. The insurance company is looking for charges unsupported by the clinical documentation. In most cases the services were provided by the provider but the provider simply failed to document the service in the clinical record. This is due to the fact that the provider checked a paper charge ticket/superbill and documented the visit at a later time. Implementing an EHR that is engineered for speed and allowing that EHR to drive the CPT/Diagnosis codes is the only way to become 100% audit proof. Anything else is simply a risk.”

To learn more about the MD Logic EHR and Practice Management solutions please contact our corporate office at 800-273-7750.