Unit Four: Systems Oriented Practice
Chapter 19: Charting effectively for reimbursement, referral, and communication
Unit Four: Class Four
Learning Objectives
4.4.1. List the requirements of an encounter chart note to demonstrate the complexity and level of care provided and CPT assigned to the encounter.
4.4.2. Explain the referral process in primary care.
4.4.3. List the requirements of an encounter chart note to demonstrate the need for referral to specialized services.
4.4.4. Describe how the various components of the primary care encounter serve as a means of communication between the various health care providers in the team.
4.4.5 Describe the methods of charting to effectively bill for reimbursement, provide information necessary for referrals to be covered, and plan for patient follow-up coordinated between inhouse and outside specialists.
Reading Assignments and Videos
Online Articles:
- “Toward Successful Coordination of Electronic Health Record based-referrals: a qualitative analysis”; Implementation Science 2011. 6:84
- Link: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3199858/pdf/1748-5908-6-84.pdf
- “Electronic Health Records and Support for Primary Care Teamwork“. Ann S. O’Malley, Kevin Draper, Rebecca Gourevitch, Dori A. Cross, Sarah Hudson Scholle. Journal of the American Medical Informatics Association, Volume 22, Issue 2, 1 March 2015, Pages 426–434, https://doi.org/10.1093/jamia/ocu029.
- Patient referrals — A Linchpin for Accountable Care: JAMA 8/2014, National Institutes of Health
- Financing of Behavioral Health Services within Federally Qualified Health Centers, Contracted Behavioral Health Financing Studies for SAMHSA; 2012
- Reimbursement of Mental Health Services in Primary Care Settings; SAMHSA, U.S. Department of Health and Human Services (DHHS); 2/2008
Online Videos:
Electronic Medical Records Examples:
- Creating a Comprehensive Treatment Plan for the Individual or Group; ICA Notes, example for a behavioral health encounter
- Centricity Practice Solution – EMR demonstration; General Electric Centricity HER, example for primary care physician encounter.
