Documenting a Visit With Our Pain Management EHR System

Documenting a Visit With Our Pain Management EHR System

Our pain management EHR, EMA®, is designed to help pain management practices as they work to deliver their best care – faster. Let’s take a look at how easy it is to document a patient visit with EMA. For more information, visit modmed.com/pain-management

Here is a full transcription of the video:

Modernizing Medicine’s pain management EHR, EMA®, is designed to help pain management practices as they work to deliver their best care – faster. Let’s take a look at how easy it is to document a patient visit with EMA.

In this example, the patient presents with insidious onset neck pain. While in the waiting room, the patient used modmed® Kiosk to add their past medical history, allergies and medications — helping to save the office staff and the physician time.

As you can see, the visit overview displays a running note view of the patient’s chief complaint, HPI, review of systems and vital signs. This information can also be viewed in a tile format depending on your clinical workflow.

After an initial exam, the provider diagnosed the patient with Cervical Radiculopathy and an associated diagnosis of Myofascial Pain. If this is a common diagnosis for your practice, you can build a Protocol on how you prefer to treat these patients, which can really help you document more efficiently.

The protocol shown here includes x-ray interpretation, counseling on Cervical Radiculopathy, Trigger Point Injections and a referral for physical therapy. Once the protocol is created you can edit it as needed for a particular patient. For example, you can delete the physical therapy referral, and add a physician-directed home exercise instead.

Additionally, you can document any custom findings specific to this patient. EMA will present suggested custom findings based on your diagnosis, which helps reduce extra clicking and tapping.

Here, you can easily add an e-prescription for meloxicam. The plan in EMA provides the estimated patient costs to help with patient communication. For patients who pay with cash, you can compare drug pricing through GoodRx and attach available eCoupons.

EMA also provides integrated access to PDMP databases for several states, allowing you to quickly analyze data associated with the patient’s prescription history, before you prescribe.

The patient’s preferred pharmacy automatically populates from the intake kiosk and your prescription, along with any available eCoupons, are sent electronically.

As you document the exam, EMA collects the required elements associated with selecting the correct E&M level in the background and suggests what coding might be appropriate based on the services provided for you to review and approve.

The visit note output is very easy to read and highlights the exam findings specific to this patient in red for easy identification.

The encounter form includes the suggested coding, which populates based on your clinical documentation, as the visit is completed. This includes CPT codes, HCPCS codes, modifiers and the E&M level. And beginning on January 1, 2021, EMA will be updated to provide the option to bill based on MDM or total time (including both face-to-face and non-face-to-face activities).

Keep in mind that you can review these suggested codes with your billing office and make changes as necessary. You should always review the suggested codes to ensure that you agree with the recommendations before you finalize the bill.

Here you will find a patient handout that includes diagnosis information, prescription instructions and post injection instructions. This handout can be printed for the patient and posted to their patient portal.

And just like that you are ready to finalize the visit and move on to the next patient.

Want to see how EMA can help save your practice time? Request a demo today.

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