Billing and Coding and Medical Transcription are core steps in the process of Revenue Cycle Management. While the medium changed from papyrus to paper, and most recently from analogue medium to digital medium, the reasons for maintaining records have also evolved from basic patient records to public health and legal records, to the most recent requirement for insurance reimbursement. Medical transcription along with Medical Billing and Coding are at least half a century old as an institutionalized established practice in the USA. A patient's medical record is an extremely sensitive document that is quoted extensively for medical, legal, and insurance purposes in the United States and becomes part of the patient's permanent medical records in the custody of the healthcare facility where patient's care is rendered.
The Flexner report on medical education (1910) was the first formal statement made about the function and contents of the medical records, which encouraged physicians to keep a patient oriented medical record. In the 1960s, hospital information systems (HIS) emerged, which helped physicians keep documents accurate. Problem oriented medical records (POMR), made in 1969 by Larry Weed, focused on the organization of all diagnostic and therapeutic plans, keeping in mind the medical problems
There are many benefits associated with improved physician documentation and record keeping. The value of this enhancement may be found in:
- Increased productivity
- Document accuracy
- Improved reimbursement, legibility
- Increased communication
- Improved patient care
Studies have shown that physician productivity increases when ER visits, progress notes and other medical reports are dictated rather than hand-written. According to industry sources, when comparing writing medical reports versus dictating, an average person can dictate 85-95 words per minute compared to 20 words per minute for writing. e.g. a document of 200 words takes about 10 minutes to write vs. 2.22 minutes to dictate. Based on this time saving and five patients per hour, this equates to saving the dictating physician up to three and half (3 ½) hours’ time per eight-hour shift.
Also, during the course of the day, a physician is likely to find one to five minutes of uninterrupted time rather than nine to twenty two minutes of writing time. Besides the actual time involved in writing the report, it is impossible to factor the inevitable interruptions encountered and delays associated with losing one’s train of thought.
The accuracy of medical reports improves greatly when dictated immediately after the patient exam rather than at the end of the day, when it is likely some crucial information may be left out. Thoughts flow faster while speaking, and "dictating" the facts of patient visit when compared to writing.
The inability to read a doctor's handwriting is an age-old problem and cannot be overlooked as a major documentation concern. This may delay critical patient care decisions, affect reimbursement, has a negative impact on medico-legal issues and increases risk management related issues.
In the era of need for cost containment, documentation is the key factor for patient reimbursement. In an ambulatory setting, payment is directly associated with thoroughness and the level of detail included while documenting patients' visits. The Evaluation and Management codes in the CPT manual determine reimbursement for services provided as an outpatient or in a physician’s office or for an ambulatory visit. The E&M codes are based on detailed documentation which includes the scope of patient history obtained, extent of the examination performed and the complexity involved in making medical decisions. Details must be included while documenting the patient’s visit to obtain maximum level of reimbursement. A poorly documented, handwritten report, with incomplete or insufficient details of a patient’s visit will result in lower levels of reimbursement.
A well documented, easily searched and indexed, comprehensive medical record goes a long way in adding to the quality of health care. Medical Transcription (MT) increases the health care provider’s productivity and document accuracy, leading to better financial reimbursement and prompt response from HMO's and insurance companies. It also helps in the reduction of medico legal issues and increases risk management, and last but not the least, enhances quality of healthcare provided.