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Cloned notes: The time is ripe to review your practices

10/16/2012

 
Mike Enos, CPC, CPMA, CEMC and Nancy Enos FACMPE CPMA, CEMC, CPC-I, CPC have authored a series of articles published in MGMA's Connexion Magazine.  The September issue featured the first part in the Code of Conduct Section, and Part 2 has now been published in the October edition.

In the September article EMR Risk- If it wasn't done, don't document it: Tackling E&M coding errors in the age of EHR's  we explored the growing trend of overdocumentation made easier by EMR's.  We discussed the causes and risks associated with overdocumentation, as well as proper ways of documenting lengthy visits to make sure you are reimbursed appropriately.  In this article, we investigate the pitfalls and risks related to overdocumentation and cloned notes specifically.

Cloned notes (using the exact same verbage from patient to patient), copied notes, and automatically generated notes should be examined closely, and physicians should be trained on how to delete, correct, and authenticate the contents of their notes to ensure that the notes actually reflect the services provided, and nothing more.  Often times in copy-and-paste notes, or other EMR notes where information from previous services are "pulled forward" into the note, we find information that is erroneous, superfluous, and sometimes directly contradictory with what is described in the history of present illness or the examination.

EHR's that have a "coding tool" can be especially risky, when the level is calculated based on data elements, and not medical necessity.

Saturday class is scheduled for Fall 2012, registration is open

3/7/2012

 
The Fall Professional Medical Coding Course has been scheduled at Kent Hospital and will begin on Saturday, September 1st with a Preview Workshop to prepare students for success!  The CPC exam will be proctored on Saturday November 24, 2012.  

The course will be held in classroom 4B of the Trowbridge Building at Kent Hospital on Tollgate Road in Warwick, RI.  Classes begin at 8am and end at 1pm. 

Tuition is $2000.00 and  includes the AAPC Textbook, Workbook, AAPC Membership fee and CPC Exam (2 opportunities to take the exam).  A deposit of $500.00 is required for registration and the balance is due on or before the first day of class.

Advance your career and attain CPC Certification.  The course will cover subjects including CPT, ICD-9, HCPCS, Compliance, the Business of Medicine, Anatomy and Medical Terminology.  Click on the "Education" tab for more information and to register.

Prepare for Success by taking the Spring CPC Preview Class

1/20/2012

 
Our Students feedback has led us to expand our CPC course, offering two Preview Classes before starting the Professional Medical Coding Curriculum which covers 21 chapters including CPT, ICD-9, HCPCS, Compliance and the Business of Medicine.

Students will feel  more prepared after taking the Preview Class with Mike Enos, providing an introduction to Anatomy and Terminology.  Mike's expertise is test taking and preparing students to understand how to succeed on an objective exam.  This preview class will also cover "Test Taking Skills". 

The AAPC tracks areas of weakness based on exam results.  The Evaluation and Management Codes are the most complex area of coding, and Nancy Enos  will cover an in-depth overview of this coding chapter in the second Preview Class..

These two Preview Classes are free of charge for registered students ($500 deposit paid).  Examinees who need a refresher before taking the exam again are welcome.  The $199 fee is discounted for former students of Nancy Enos Medical Coding.

The Professional Medical Coding class will begin on Tuesday March 13, 2012 and will meet on Tuesday and Thursday evenings from 5:00pm to 7:30pm through Thursday May 24, 2012.  The class will take the CPC exam on Saturday May 26, 2012.  Registration is open, click on  "Education" to learn more and register.
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    Mike and Nancy are independent consultants and coding educators.  They are a mother/son team who are active in local and regional professional organizations.

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