Health Care - Specialties - EMD Systems Software Private Limited

Healthcare

EHR Suite

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E/M Coding

EMR

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Meaningful Use

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HL7

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General

General Data Protection Regulation(GDPR)

HEALTHCARE

Healthcare is the diagnosis, treatment, and prevention of disease, illness, injury, and other physical and mental problems in humans. Health care is administered by medical practitioners, optometry, dentistry, nursing, pharmacy, allied healthcare providers. It involves the work in providing primary care, secondary care, and tertiary care, as well as public health. It is known that access to health care varies across countries, groups and individuals, largely influenced by social and economic conditions as well as the health policies in place. Around the world, every health care system is struggling with rising costs and uneven quality despite the hard work of well-intentioned health providers and the governments. Today, it is the call for a new strategy, that is a patient centric strategy rather than a physician oriented strategy. Definitely technology plays a unprecedented part in shoring up the outcomes of healthcare. The innovations in diagnosis, treatment and patient care has taken healthcare to a different realm. innovative breakthroughs in molecular biology, stem cell research, bionics, organogenesis, synthetic biology, and artificial intelligence in order to improve health care and extend healthy living. Now, we look to accelerate the real-world impact of science, technology, and information related to the worldwide optimization of health and the elimination of illness and disease.

E/M CODING

EMD has developed an application that helps providers ensure correct coding of evaluation and management (E/M) services.

Healthcare players may require reasonable documentation to ensure that their service is consistent with the patient’s insurance coverage and validate it, like

	The location of service
	The medical necessity and appropriateness of the diagnostic and/or therapeutic services provided; and/or
	That services furnished have been accurately reported

There are general principles of medical record documentation that are applicable to all types of medical and surgical services in all settings. While E/M services vary in several ways, such as the nature and amount of physician work required, the following general guide principles for evaluation and management services help ensure that medical record documentation for all E/M services is appropriate.

	The medical record should be complete and legible;
	The documentation of each patient encounter should include:
	Reason for the encounter and relevant history, physical examination findings, and prior diagnostic test results;
	Assessment, clinical impression, or diagnosis;
	Medical plan of care; and date and legible identity of the observer.
	If not documented, the rationale for ordering diagnostic and other ancillary services should be easily inferred;
	Past and present diagnoses should be accessible to the treating and/or consulting physician;
	Appropriate health risk factors should be identified;
	The patient’s progress, response to and changes in treatment, and revision of diagnosis should be documented; and the diagnosis and treatment codes reported on the health insurance claim form or billing statement should be supported by the documentation in the medical record. In order to maintain an accurate medical record, services should be documented during the encounter or as soon as practicable after the encounter.

EMD's software helps make this complicated and sometimes confusing process easy and fast. This ensures that the patient is charged fairly, the provider is compensated fairly, and the liability of Medicare / Medicaid fraud is reduced.