In circa 1996 I audited my first Radiation Oncology chart. Little did I know almost twenty years ago this would become a long career of digging through document after document to justify the billing of the twisted and confusing 77000 series of codes.
Needless to say in 1996 all records were 100% paper charts, from the trifold treatment logs to the specialized high dollar paper our planning systems printed on our charts were documented page by wonderful shiny beautiful page. Very few places even had true record and verify although that was beginning to happen clinic by clinic. I remember how gorgeous the first 3 dimensional isodose plan stood out in charting. It truly was art at times, the beauty of anatomy and isodose lines.
Times change, computers now are in every office of every clinic. Electronic Medical Records (EMR) have been pushed the forefront in many ways. Most importantly it has been linked to our payment system and driven rapidly into place by the Federal Government.
EMRs have thoroughly corrected our date of service issues in Radiation Oncology. The system does this automatically, which most of us have realized by now, can be in our favor or to our derailment in billing of services. The amazing wealth of information in the “information age” has dramatically increased the volume of information available in almost every setting (although each has its very own auditing processes). Of course each auditor has his or her own process too. There are many, many ways to reach the correct answer in auditing our medical records.
That volume of information has made organization of the medical record within our EMRs varied and complex. There are charges in Radiation Oncology buried so deep in some of our EMRs that only the medical physicist has privileges enough to reach the document. Many of today’s environments allow remote access using multiple computers views. One incorrect setting in an EMR and the user can accidently hide complete courses of Radiation Therapy. The linking of multiple software systems through interfacing has confused what information is really stored where. Where does that information really need to be? Who needs access to that information? And of course we all know that some software has soared above the others at these questions, while others have the bar necessity to be useful.
The long story short, even though we have multiple new tools for documenting the medical record now, and even though (in the grand scheme of things) the rules are still the same, if you didn’t document it, you didn’t do it. Plus, every auditor in today’s world still requires you to print to paper (or a pdf type form much like paper). Simply put, if you can’t produce a paper document you are going to have issues. Why, no auditor from a, insurance company would know how to use every software system in the industry, only the old days of paper make that possible.