Tag Archive for Transcription

Medical Transcription and Coding demand will increase with ICD-10

Medical Coder and TranscriptionistThe world of medical transcription and medical coding is extensive and always changing. The change that has the medical field buzzing right now is the change from ICD-9 to ICD-10 (International Classification of Diseases – Version 10). Currently, health care facilities use ICD-9 for documentation and coding, but by October of 2014 every facility must abide by the new system. These new changes will increase the need for skilled medical transcription and medical coding. It will also bring these two jobs expertise closer and merge at some time in the future.

Why will demand for transcription and coding increase?

For healthcare employees already working as a medical transcriptionist or medical coder, they don’t need to worry about these changes affecting their chances of employment. The truth is that the need for these highly skilled workers will actually increase with the implementation of ICD-10.

One of the main reasons for the increase of work is that the new book of codes is a lot more specific than ICD-9. For instance, in ICD-9, the code for a burn on the left arm is the same code as a burn on the right arm. While this may not matter to the insurance company, it does matter to the treating physician, the patient and the transcription. There are not numerous new diseases in the new manual, but it will have over 70,000 codes listed. These are also going to be seven digits, instead of the five seen in the past. The increase in codes and length of codes will help the medical coder be more specific.

There is no substitute for an intelligent human mind, so the fear that medical transcription will be obsolete after the new implementation is unfounded. Both transcriptionist and coders will actually have to work harder and attend more training to become compliant. The new system may be confusing and overwhelming to those who have worked on ICD-9 for years. As these older employees leave the workforce, fresh new recruits will be needed.

Importance of Implementing Electronic Health Records (EHRs) from ICD-10 prospective

In order to be compliant with the new rules, healthcare facilities will find that having an efficient EHR (electronic health record) system in place first will be a huge benefit. There are still thousands of private practices that have not made the switch to electronic medical records, but this will hurt them when they must face compliance with the new coding regulations.

By implementing an easy to use and efficient EHR, the transition to ICD-10 will be a lot smoother. If a facility does not yet use computers for their records, they should consider doing this as soon as possible to be ready for the upcoming coding and documentation changes.

The reason an EHR is so important is because it helps streamline the coding process. It is much easier to use a search function on a computer than trying to pore through hundreds of pages in a patient’s chart to find information. To determine whether an injury was on the left or right side of the body, for example, the coder can simply search for this terminology within the patient’s electronic record. To find this information in a paper chart wastes hours of valuable time.

How will the New System Help Medical Transcription?

It may be true that the new system will mean less hours of transcribing work but it doesn’t appear transcription will be absolute. In fact, those that choose to stay in the field and learn ICD-10 coding will be rewarded with more hours than ever of transcribing work.

Because ICD-10 demands greater detail, physicians will have to begin giving greater detail in their records. This translates into more words for the transcription, which equals greater pay. Also, the increased need for transcription with coding expertise will mean better rewarding opportunities.

Tags: EHR, Electronic Health Record, ICD-10, ICD-10 Coding, ICD-9, medical billing, medical coding, Medical Documentation, Medical Transcription Service

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Verbatim Transcription

Should doctors be taken word-for-word?

By Cheryl McEvoy

A run-on sentence. A misspelled drug. A superfluous comma. Heck, maybe even a split infinitive. Dictation errors can irk word-wary MTs, but should they be forced to overlook such grammatical offenses? Thus begins the debate over verbatim transcription, a contractual item that makes MTs withhold all judgment — medical, grammatical or otherwise — and simply type what the dictator says. The controversial practice pits risk management against quality assurance (QA), but MTs’ reputations and patient care are what’s on the line.

While traditional transcription lets MTs correct punctuation, misspellings and dictation errors at their discretion, verbatim transcription requires MTs to transcribe notes exactly as dictated. The practice is usually based on the client’s preferences; if a doctor doesn’t want his words altered, the MT is expected to transcribe word-for-word. There are arguments for and against the no-edits approach, but most MTs aren’t thrilled about it.

The running joke is, “If you want verbatim transcription, I will put in every ‘uh,’ ‘ah,’ ‘oh’ and ‘um’ that you have dictated,” said Barb Marques, CMT, AHDI-F, president-elect of the Association for Healthcare Documentation Integrity (AHDI).

In reality, it’s no laughing matter.

Risky Business

Doctors can make mistakes, so risk managers champion verbatim transcription as a way to keep MTs from taking the fall, according to Donna Brosmer, CMT, AHDI-F, NREMT-B, quality officer, Spheris. If the document ends up in court, an MT can claim no culpability because the doctor requested the dictation be transcribed word for word. If the MT changed any words, he or she might be held accountable for the error – a mark hospitals and medical transcription service organizations (MTSOs) don’t want on their hands.

But many say verbatim transcription neglects the value a skilled MT can bring to the table. With knowledge of diseases, diagnoses, treatments and medical terminology — not to mention, a knack for grammar and punctuation — MTs can serve as the first line of defense against errors, according to Brosmer. “You have a group of very intelligent people creating these reports, transcribing these reports,” she said.

For example, a good MT would know the difference between Xanax and Zantac and could correct the mix-up if a doctor misspoke, Brosmer said. MTs are also trained to notice when a doctor switches between left and right.

“If he said ‘right foot’ five times in the report and he gets down to the bottom and says ‘left,’ 99.9 percent [of the time], he really does mean the right foot,” Marques said.

Errors like that are becoming more common as good dictators become few and far between. With doctors able to dictate from their Blackberrys and iPhones, MTs are struggling to hear over the background sound of gyms, pools and oncoming traffic, Brosmer said.

Physicians are also getting more lax. Marques said today’s rising doctors do not speak in complete sentences, making it harder to understand the report. While a skilled MT would have the confidence to edit and make corrections without delaying the report, with verbatim transcription, the MT would have to query the physician or flag errors in hopes he would re-examine his work.

Making matters worse, many doctors don’t review their transcribed reports, according Lesli McGill, director of U.S. operations, SPi Healthcare. McGill hails from the “old school” of transcription, where she learned to edit as she transcribed. She recalled the “rubber stamp” method physicians used to approve reports — simply passing it on without so much as a glance. In today’s electronic environment, that stamp has been replaced with a click of approval, making it even easier to overlook flagged items.

Employee Pride

What the controversy boils down to is quality. MTs pride themselves on delivering a timely and accurate record, so they loathe initialing a document that isn’t up to par — especially if that document is hauled into court. “[MTs] want people to understand they did the best job they could with that document,” McGill said. “It reflects badly on them if it’s a verbatim account and you’ve got a bad dictator.”

The squabble isn’t likely to end soon, the experts said. The topic was among discussions at the Medical Transcription Industry Association (MTIA) Convention last April, and it’s expected to be on MTs’ minds at the AHDI conference later this month. In health care, quality isn’t something to take lightly; a mistake that slips through the cracks could mean the difference between life and death. MTs are supposed to be the first defense against errors, but amid the skirmish of lawsuits and legal liability, some fear verbatim transcription will push patient care to the wayside.

Cheryl McEvoy is an editorial assistant with ADVANCE

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Transcription Technology Watch

This is the first in a series of quarterly articles that will focus on technologies relevant to medical transcription. Hopefully, maybe even those MTs who are techno-phobic will find some of the topics enlightening, stimulating and/or of value in making career decisions. But maybe not. To challenge that hope, I’ve started off with everyone’s favorite technology: speech recognition. If you want to really stimulate a transcriptionist, just say “speech recognition.” Or, better yet, assert that “speech recognition will forever change the process of converting physicians’ thoughts and utterances into text.” Then run for cover.

Every transcriptionist out there has heard some form of that assertion. Their reactions range from dismissal to fear to anger. So what’s the truth? What does the future hold? Well, at some point in the future, there will be no medical transcription. Physicians will dictate into a PC or portable device; their speech will be converted to text; and the dictator will make any necessary corrections to finalize the report. No transcription expense. No transcription delay. But that future is at least 3 years off. Just kidding. It’s way more than that. However, there is a future closer than that, related to speech recognition, which has some major implications for this industry.

Doctors hate doing anything that they believe is below their stature or slows down their ability to generate revenue. So we will not see “front-end” recognition-where they correct their own mistakes as described above-in most environments for many years. But there’s a new game in town. It’s called “back-end” speech recognition. Physicians don’t change a thing in their dictation behavior. They continue babbling into telephones or some other dictation device just like they always have. But their voice files are now run through a server-based recognition engine, a draft is produced, and a medical editor corrects the errors both in recognition and dictation.

This technology is truly beginning to get some traction. Physicians love innovation, but they hate change. So this suits them just fine. In fact, they typically don’t even know it’s going on. The goal of back-end speech recognition is to at least double the productivity of transcriptionists. And to do it for about a penny a line. Most implementations are not quite there yet. Speech recognition talk has always been ahead of speech recognition technology. Nonetheless the handwriting is on the wall. This technology will begin to transform transcription in the coming years. So it seems wise for MTs to learn more about it and perhaps even to embrace it.if they like what they learn.

Currently, it is prohibitively expensive for an independent transcriptionist or small transcription company to purchase a recognition server. However, there are a number of ASPs popping up, which charge by the line to produce a draft. I could tell you a lot more groovy stuff about this rather exciting technology, but I’m just about out of my allotted space. So tune in next quarter for the second Watch article, which will explain more about how it works and what it means for medical transcriptionists. Unless, of course, I feel like writing about something else.

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