Implementing a Centers for Medicare and Medicaid Compliant EMR for Outpatient Visits

In the last decade, Federal and State governments, employers, health insurers, clinicians, consumer advocates, and consumers have become keenly aware of healthcare costs and medical errors.  In fact, this awareness is the impetus for major change in our healthcare system. Managing costs while ensuring patient safety has become a key strategy in driving reform. In that vein, several acts have addressed healthcare costs: the 1997 Balanced Budget Act mandating the largest cuts in Medicare history, the 2006 Tax Relief and Healthcare Act approving a permanent Recovery Audit Contractor program, and the 2009 American Recovery and Reinvestment Act promoting an EMR Stimulus Package. Simultaneously, strides have been made to endorse national standards and promote electronic health records. In 1998, the Advisory Commission on Consumer Protection and Quality in the Health Care Industry called for a “national commitment to the measurement, improvement, and maintenance of high-quality care for all Americans”and by 2000, the Institute of Medicine had identified comprehensive ways to improve patient safety. In order to comply with the national effort to provide cost-effective safe care yet optimize reimbursement, WOC nurses must embrace EMR systems and ensure their documentation meets CMS charging guidelines.

Realizing the need for consistent documentation by nurses and physicians in our outpatient wound center, an electronic visit record was developed that is compliant with CMS guidelines. This record incorporates verbiage which is repeated on the bill sheet to promote clarity and consistency and support that the care provided matches the charges to insurers. Since the implementation of this record, we have improved documentation and reduced charging and coding errors as measured by monthly record reviews.

In today’s era of economic uncertainty, reimbursement is critical to the healthcare sector’s viability. Clinicians must ensure that documentation accurately represents the service charged and complies with CMS guidelines.