EMR to Billing Workflow

The strength of the PatientTrac system is effective workflow management. The main objectives of the complete workflow are:

  • to capture all billable incidents and items from the initial point of contact with a patient and submit a claim for reimbursement to the insurance payer
  • to build an insurance reimbursement model based on accurate eligibility information and timely claim submission, with detailed tracking of payments and benefits

Our workflow model begins with the initial patient contact, when a patient calls the office to inquire about appointment availability. During this initial contact, the administrator obtains insurance and demographic information and enters it into the PatientTrac Practice Management application. Insurance eligibility can be verified immediately, and copay/responsibility information can be provided to the patient over the phone. Alternately, eligibility can be verified at a later time during preparation for the patient’s appointment.

Once insurance eligibility has been checked, the administrator determines the approved visit types, or limitations a specific insurance company may have for the approved visit level. Eligibility results also include any requirements for pre-authorization for different provider types (e.g. MD vs. therapist). Based on the insurance eligibility and the needs of the patient, the scheduling team can configure the most effective use of time for physicians and clinicians in the practice.
Our practice management application works in conjunction with the EMR encounters to identify the appropriate level of visit for office visits, substance abuse visit and inpatient visits.

The next step in the workflow is encounter creation by treating provider. The EMR generates an encounter and a progress note based on the appointment type for the specific level of visit. During the visit, the provider has the ability to up-code or down-code the visit level or change the visit type based on the duration, complexity and nature of patient interaction. If any additional procedures, such as rating scales or smoking cessation discussion, have been completed during the visit, they will be added to the E/M component and can be added to the superbill by either treating provider or administrator.

On the EMR side, software documents each of the E/M elements which have been completed by the provider during the scheduled visit.

Our evaluation and management component calculates the level of visit which has been documented within PatientTrac EMR, and presents the appropriate CPT code for the visit to the billing department. Additionally, the software captures specific events during the visit which are billable as separate and additional procedure codes.

For example, a social history documents whether patient is using tobacco products. If the provider has a smoking cessation discussion with the patient, PatientTrac captures the billing code for smoking cessation and adds the CPT code and CPT modifier for the smoking cessation in the E/M. In the event the provider documents an alcohol or substance abuse screening evaluation, PatientTrac captures and documents the appropriate CPT code and CPT code modifier for that procedure. And if the provider completes psychiatric tests or rating scales during the visit, the software captures and documents the appropriate CPT code and modifier for reimbursement of the psychiatric tests or scales.

Once the provider is finished with the visit, an electronic superbill is ready and available to the administrative personnel. They can then schedule a subsequent visit. During checkout, payment is entered into superbill, which can be printed out as a receipt of payment (along with upcoming appointment information) and handed to the patient. At this point, an insurance claim is complete and ready to be submitted for reimbursement. The completion of the superbill is the final stage of the patient visit, which is now ready for electronic claim submission to an insurance payer. There is no double data entry by the administrative staff; all work completed by the doctor in EMR automatically translates into an EDI claim.

While the workflow concept is not a new one, PatientTrac system has effective, easy-to-use tools for each of these critical steps.

These convenient tools benefit both provider and administrator. From the provider’s perspective, each visit presents its own complexity. The billing code may change during the visit, or there may be additional procedures added. These additional billable procedures may be medically necessary, but may not have been anticipated by the scheduling staff. Physicians/clinicians do not have to give any separate coding and billing instructions to the staff. All coding information will be seamlessly incorporated in the final bill. Each EMR encounter becomes a complete claim with CPT and diagnosis.

With PatientTrac, the communication between the provider and administrative staff is complete and automatic. After the visit is finalized, administrative staff has the complete claim information (e.g. CPT codes and modifiers, where necessary, and billing diagnosis) ready for claim submission.

The main advantage for administrative personnel of using PatientTrac is the communication with the provider. There’s no need to enter billing data twice, diagnosis and CPT codes are done when the EMR note is done, there are no paper instructions, and there’s no need to track down busy doctors for clarification.