Electronic Medical Records and Medical Billing Procedures

Overview of Electronic Medical Records (EMR)

• role of the health care professional using EMR
• advantages and disadvantages of EMR
• differences between paper files and EMR
• selecting an EMR vendor

Privacy, Confidentiality and Security

• role of the health care worker in regard to EMR security
• review of medical law and ethics and patient rights
• importance of passwords
• breach of confidentiality consequences

Transitioning from Paper Charts to EMR

• planning for a successful transition
• office procedures requiring workflow re-design
• conversion of the paper chart to digital
• what happens to the paper chart

Establishing and Maintaining a Patient Registry

• patient registration
• entering demographic information
• past medical history, allergies, immunizations and clinical data such as height and weight

Entering Prescription Details into EMR

• understanding prescription parts in relation to EMR
• how to find brand and generic names
• enter a complete prescription record on behalf of the physician
• print a prescription record

Administrative Uses of EMR

• messaging
• referral letters
• diagnostic tests
• patient education in regards to diagnostic tests
• laboratory reports
• overview of chronic disease management and complex care

Appointment Scheduling

• differences between paper and electronic appointment scheduling
• introduction to different parts of the appointment scheduling screen
• making an appointment
• changing an appointment
• cancelling an appointment
• dealing with no-shows
• printing an appointment card
• printing a daysheet/schedule for each physician

Alternate billing and required form completion

• WorkSafe BC
• Insurance Corporation of B.C.
• private insurance
• medical-legal
• cash, self-responsible patients
• out-of-province claims
• non-medically required services
• hospital visits

Medical Services Plan

• CareCard information
• preamble
• fee schedule - MSP and Doctors of BC
• location codes
• diagnostic codes
• specialty codes
• practitioner and payment numbers
• claims processing system
• remittance statements and explanatory codes
• claims coverage enquiry

Claims processing information

• required claims processing information with regard to manual day sheets
• required claims processing information with regard to electronic medical billing
• billing from the appointment schedule
• electronic medical billing to a variety of insurers – MSP, Work Safe, ICBC, Private and Out of Province
• computer-generated reports and electronic claims processing
• understanding the importance of dealing with rejected claims in a timely manner
• understanding why a claim was rejected – use of explanatory codes