Know Your Terminology: Health IT 101

Thursday, 17 November 2011

Understanding the basic terminology is a critical piece of the puzzle towards establishing creditability with a physician and/or practice manager. The medical community is experiencing industry wide changes at a rapid pace and the vendors who have done the research and understand those changes will gain a competitive advantage over their less informed competitors.

Pursuing the development of a robust healthcare vertical can provide fulfillment and opportunity on many levels, but being successful requires knowledge of certain related terms. To perform successfully, healthcare vendors/professionals should have an understanding of key medical-related terminology dealing with the physician, their office and overall operations of the practice. Understanding the various front line terminologies can help with your credibility in the eyes of the practice and ultimately, the sale.

First we'll offer a brief overview for the uninitiated and the delve into some specific terminology. Most vendors typically are working within physician practices to assess their IT hardware infrastructure and are involved in the selection and purchase of an Electronic Health Record (EHR). Incentive money is available from The Centers for Medicare and Medicaid (CMS) as a result of the Health Information Technology for Economic and Clinical Health Act (HITECH) and Meaningful Use (MU).

The Medicare and Medicaid EHR Incentive Programs provide a financial incentive for the "meaningful use" of certified EHR technology to achieve health and efficiency goals. By putting into action and meaningfully using an EHR system, providers will reap benefits beyond financial incentives-such as reduction in errors, availability of records and data, reminders and alerts, clinical decision support, and e-prescribing/refill automation. For eligible professionals, there are a total of 25 meaningful use objectives. To qualify for an incentive payment, 20 of these 25 objectives must be met.

  • There are 15 required core objectives.
  • The remaining 5 objectives may be chosen from the list of 10 menu set objectives.

(Source: CMS.gov)

Eligible professionals (EPs) are eligible for up to $44,000 per provider if participating with Medicare or up to $67,000 if participating with Medicaid. Eligible professionals under the Medicare EHR Incentive Program include:

  • Doctor of medicine or osteopathy
  • Doctor of dental surgery or dental medicine
  • Doctor of podiatry
  • Doctor of optometry
  • Chiropractor

Eligible professionals under the Medicaid EHR Incentive Program include:

  • Physicians (primarily doctors of medicine and doctors of osteopathy)
  • Nurse practitioner
  • Certified nurse-midwife
  • Dentist
  • Physician assistant who furnishes services in a Federally Qualified Health Center or Rural Health Clinic that is led by a physician assistant.

For additional requirements please reference: CMS.gov

To be classified as an EP the provider must posses a National Provider Identifier (NPI) which is a unique 10-digit ID number issued to healthcare providers in the United States by CMS.

Physicians who choose to participate with MU must select an EHR that has been certified by the Office of the National Coordinator (ONC). ONC is a division of the Office of the Secretary (OS) who has been tasked with implementing and coordinating the exchange of electronic health information nationwide.

For the past 15 years physician practices have been submitting medical claims through their practice management system (PM) or claims are outsourced to a billing and collections agency. Typically the practice is paying 5-7% of collections to that outside agency. Claims are generated from information gathered from the super bill which is created using documentation from the patients' healthcare visit by the clinician. The information from the super bill is then entered into the PM, which generates a claim. Claims are submitted to a third party entity or clearinghouse. Claims are then "scrubbed" which means they are verified for eligibility, demographics, physician NPI number, and diagnosis codes (International Classification of Disease or ICD-9) are matched with the Current Procedural Terminology (CPT) codes.

The current ICD-9 code set is changing effective January 1, 2013 and clinicians will be expected to generate claims using the ICD-10 code set. Because the ICD-10 code set is more specific and detailed oriented, the adoption of a certified EHR prior to tackling a coding change can make this a much smoother process for the practice. Evaluation and management codes (E&M) are a subset of CPT codes that specifically address the level of care given to the patient. For example, an established patient who had 15 minutes of "face" time with the doctor for the follow up care of an infection could bill an E&M code of 99213. This code indicates to the health insurance carrier that the presenting problem was low to moderate in nature. Documentation off the patient visit is critical in the event of an audit. Most clinicians follow a structured set of documentation guidelines called SOAP notes. "The SOAP note (an acronym for subjective, objective, assessment, and plan) is a method of documentation employed by health care providers to write out notes in a patient's chart, along with other common formats, such as the admission note. Documenting patient encounters in the medical record is an integral part of practice workflow starting with patient appointment scheduling, to writing out notes, to medical billing" (Source: Wikipedia).

The Place of Service Code (POS) is a key indicator on a claim that designates whether or not an EP qualifies for the incentive money and also determines the level of reimbursement. The POS is noted on the claim, this informs the health insurance carrier where the services were rendered. For example, 11 - indicates physician's office, 21 - in-patient facility (patient is admitted into the hospital and is staying longer than 23 hours), 22 - outpatient facility, 24 - urgent care facility. If over 80% of the physicians care is administered to patients with a POS 21, the physician does not qualify to participate with MU.

A benefit to having an EHR is Computerized Physician Order Entry (CPOE), an application that enables providers to enter medical orders such as treatment plans, prescriptions, labs and referrals into a computer system. E-prescribing (eRX) is another application that works with the EHR to help reduce medical errors. eRX allows physicians to electronically send an accurate, error free, legible medication order to the patient's pharmacy of choice. Utilizing the eRX feature will help satisfy one of the MU requirements.

Look for future installments of our primer in medical terminology for VARs! Once we complete the series we will offer a quick reference guide in PDF for for those we are interested, be sure to sign up to receive updates in the right hand column!

Category: Channel Education