The Ophthalmology EHR System for Retina Specialists

The Ophthalmology EHR System for Retina Specialists

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Here is a full transcription of the video:

Hi, I’m Dr. Michael Rivers, Director of EMA Ophthalmology at Modernizing Medicine. Today I’m going to show you how our  ophthalmology EHR system, EMA, uses an adaptive learning engine, Protocols, drawings, and automatically suggests coding to help you efficiently document a visit.

Before entering the exam room, you can open up the progress note to show exactly what brought the established patient in for today’s visit. From here, we can navigate to the drawing tools and draw in different locations of the eye. In this instance, I will go right to the fundus.

On the left-hand side, you can see our adaptive learning engine at work. This list includes the items that I draw most frequently. I’ll go ahead and select drusen, and I’ll place those drusen in the macula of both eyes.

Our ophthalmology EHR labels the color drawing and, in addition, will backfill the finding in the exact location in my exam. When I go into the exam itself, I have the option to document findings in the exam if I prefer, but typically I just use this exam set to document a few features. Here I note the CD ratio and quickly copy it to the other eye.

Next, I can select a diagnosis from the left-hand column based on what I do most often. However, for this demonstration, I’m going to do something a little quicker and go to my Protocols. These Protocols are preemptively built-in diagnoses and plans of action based on what I do most frequently, like a macro.

As an example, I will go ahead and select the one for dry AMD. I’ll toggle to purple on the right-hand side, and you’ll notice that everything is already filled in based on what I do most frequently like preemptively adding the staging for ICD-10.

You can have protocols set up for mild/early stage, intermediate or advanced stage, and so on. You can set up different MIPS quality measures in different Protocols. In this particular Protocol, I also have an FA and an OCT documented along with the follow-up visit. With that one-touch, and after I save, I now have documented my entire visit.

There’s macular degeneration in both eyes, including my staging, MIPS quality measures and my counseling with an AREDS talk track. Additionally, an extended ophthalmoscopy is pre-built in, along with an OCT, a follow-up for next visit and a fluorescein angiography with all of the interpretations already complete.

I can also change any of these pre-done interpretations. If I touch resume, I can add the central retinal thickness to the OCT. I can also change the findings that have already been pre-populated in my Protocol. I can document the OCT diagnosis and will say this was done as a baseline examination.

Once I save my visit note, my entire visit is done. All of the charges are documented for me automatically in the background.

It’s important to note that our ophthalmology EHR provides a suggested billing code based on your documentation. Based upon my documented visit, I have provided a medical exam and evaluation with initiation or continuation of diagnostic and treatment program; comprehensive, thus the system suggests a 9-2-0-1-4. You can override it if you wish, but I’m going to stick with the 9-2-0-1-4. You’ll notice right in the middle of the screen under the diagnosis that we have appropriate ophthalmology ICD-10s and laterality documented. We also have ICD-9 in parentheses as a reference.

My charges are shown based on the patient’s medical insurance. As I go through here, you’ll see every charge from what we did today. This includes the fluorescein angiography, the OCT and the extended ophthalmoscopy all with the modifier. This is all a result of using that Protocol.

I can also go into the note output and see exactly what was done today. Here’s my complete note with all the history on the left and the visit on the right. All of my findings are here. Keep in mind that the drusen has backfilled to the macula OU yet the lens findings and the CD ratio I entered in the exam itself.

You’ll also notice the encounter form, which shows a billing breakdown or an audit-proof sheet detailing what I have diagnosed today. The ICD-10s, laterality, CPTs, modifiers and all of our charges are included, and it explains the E&M breakdown as to why I was able to achieve that level of coding. If something’s missing it will tell me in this sheet.

When I go to the CMS 1500 form, it’s all filled in based on my documentation. The patient handout will explain what I have talked about with my patient. And with that, I’ve completed my complete documentation and billing information.

I encourage you to learn more about our ophthalmology EHR. Visit our website and request a demo today.

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