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You Asked, We Answered: Which EMR to choose?

Many of you, and many EMR companies, have asked us for our recommendation for EMR or practice management software. We are also often asked which integrated system we prefer (an all-in-one system that has all the practice management functions plus EMR). We have spent several years now experiencing different platforms and products, and asking for demonstrations from various companies.
What is the difference between practice management systems and EMRs? Practice management programs typically include functions like scheduling, billing, claims processing, and claims tracking. They work with a clearinghouse to send your electronic claims. On the other hand, EMRs automate the documentation, storage and retrieval of patient records.
Obviously, our top choice for practice management software is CollaborateMD, which is why we continue to use it year after year. If customers come to us with a different preferred program, we are happy to work in their software as well.
Unfortunately, we have not yet found an EMR that we feel we can reasonably recommend. This is mostly because we work with such a diverse group of providers and practices. Some of you are required to utilize electronic charting; some are not, but enjoy the convenience of these programs.
Because of your diverse needs, we are committed to working within whichever EMR or practice management system you choose to use. There are nearly limitless choices, and LBS can work with you in any of them.
A warning about integrated systems: There are all-in-one programs out there that charge a percentage and promise billing and follow-up along with the use of their software. Please be careful! These programs offer very little in the way of customer service, and what they don’t tell you is that you still need to have in-house staff or a billing service doing your billing, coding, and follow-up.
Here are some helpful tips when choosing an EMR:
• Consider your growth potential. For example, if you do (or you think you may in the future) accept Medicaid or Medicare clients, then invest in a system that is approved by CMS for this purpose. It is difficult enough to navigate those governmental systems; don’t put yourself through learning a new charting system at the same time!
• Consider your budget. There are products that range from free to thousands of dollars; they generally accomplish the same things, but some are more specialized than others, and some simply look a little better than others.
• Consider security. HIPAA and HITECH security is an absolute must in any system. If you have a web-based program, what do they offer you for security? Does their agreement completely indemnify them? If so, that’s not good for you. Do they have a significant amount of documentation and paperwork explaining how they secure your clients’ Protected Health Information? Are they willing to sign a Business Associate Agreement to share liability in the case of a breach?
• Consider data. What happens to your chart info (which you are required to store for 50 YEARS after the death of the patient) if you leave the company or change programs? Will you have to pay to get your data? In what format can you receive it?
• Consider ease of use and access points. Do you have to pay per computer or ISP that accesses the system? Do you have to pay extra per staff/user? Do they offer training to you and your staff? Can you easily train new staff how to use the system once established? If the system is not web-based, then how will you submit electronic chart notes, and how will your biller access the system? If the EMR downloads to your phone or iPad, what happens if you lose it? Is there a process from the program provider to clear your device for you and absolutely prevent the loss of Protected Health Information?
• Consider billing functions. EMRs do not send out insurance billing. They can produce an invoice and/or a superbill, but you must still have a practice management software program (like CollaborateMD) to actually submit and track your claims. EMRs can automate or support your responsibility to choose codes and set pricing, but they do not replace the work of a biller or billing service to properly submit those codes to insurance payers, nor do they indicate processing information or collect payment.
• Consider benefits functions. Some EMRs have the ability to ‘check benefits’. Our billing software also has this function, and for a few cents a one-line report comes back usually stating the general in-network percentage and deductible. These automated reports will not tell you anything about out-of-hospital birth coverage, midwifery coverage, newborn claims coverage under the mother, preventative services covered under the Affordable Care Act, out-of-network coverage, family deductibles etc. We have found that they are rarely useful to our customers at all.
As with so many issues in our industry, we sincerely wish that the answer was simple. It costs close to one million dollars to create a decent EMR (which is why we haven’t built our own), so they are often just not specialized enough to meet your every need. And some of those that seem the most user-friendly have fatal flaws in the way of security.
That being said; Collaborate MD has a list of EMRs with which they are able to interface. This could create for you the most seamless charting-to-billing system, and it is assured that with those options, CMD has done some of the work for you in regard to HIPAA, HITECH, access and billing.
You can access this list at http://www.collaboratemd.com/electronic-health-records/ehr-emr-partners.
Questions about EMRs, billing tools, and how LBS can work within your chosen system can be posted in the comments section right here on our blog. We will respond to you!

Billing Facility Fee for Homebirth

Dear Midwives,

I have recently heard about other billing services that are promising and getting facility fees paid for home birth midwives. My first thought was, “Thank goodness, now maybe I can get some compensation for that CCHD pulse ox I had to buy last year, and that Doppler I dropped in the birth tub last week!” We all know the burden of hauling bags of equipment and supplies from place to place, and the heartbreak of tossing expensive expired medications that we rarely use, but must have at the ready for every client.

I immediately brought this to the attention of Christine and our senior coders.

Larsen Billing Service has investigated all of the possible codes for facility and supplies, and I feel moved to share with you what we have discovered:

• Facility Service Payments are not payable under CPT or Revenue codes for births that occur at home. Billing a facility code when there is no facility cost, like rent, utilities, insurance etc., constitutes fraudulent billing according to every resource that we can find.
• Even midwives who own or have privileges at birth centers or hospitals are not eligible for this kind of compensation when the labor and birth happens at home.
• Billing under a birth center for services that do not occur there is insurance fraud.
Of course this is confusing, because if the claims are paying, what is the problem, right? Well, here is what else you need to know:

• Coding is not universal, and there is certainly the possibility that there is a midwife out there with a contract with some insurance plan, whom may be allowed to bill a facility code for homebirth supplies. We have never seen one, but anything is possible. However, that does not mean that this is applicable to any other midwife practice or any other insurance plan. That’s one of the problems with most of the billing resources floating around the internet and within the midwife community. What works for one practice does not apply to anyone else, and may inadvertently be fraud, despite the author’s best intentions.
• You, the provider, are responsible for coding. Billing services, even this one, give advice and make suggestions on coding all the time, but if you cannot find evidence in the code books for the advice as it pertains to your services, you should not allow them to bill on your behalf. So even if your billing service picks your codes, you have ultimate responsibility for all of them.
• States vary, but there is no overall statute of limitations on take backs, audits, or insurance fraud. That means that even if a code pays for ten years, it could be audited or investigated by the insurance company or local authorities, and you will be held liable to pay back, usually with interest, all funds that were improperly coded. A good billing service stands by their billing and coding and will help you gather the needed information in the case of an audit.

All of that is pretty scary. Believe me, even with my years of experience at LBS, the nuances of billing and coding for my practice have kept me awake at night. The fact of the matter is that coding and insurance billing is not a system built around the midwifery model of care, our business models, or our traditions. Sadly, in order to play the insurance game, we have to work within their system, not ours. For most of us that means we have to know more and participate more in the flawed western medical and bureaucratic medical insurance systems, way more than we ever wanted to in order to do the work we have been called to do.

I can promise you this:

• Larsen Billing Service is constantly surveying contracts, State and Federal actions, and case law in regard to coding practices and standards.
• LBS is committed to finding all of the legitimate codes for midwifery and birth center services and maximizing reimbursement to your practice and your clients.
• We change how and what we bill in response to these findings, and we utilize multiple outlets to inform our customers of best billing practices.

In the meantime, donate those expired supplies, document the cost of that pulse oximeter, and write off every single business expense that you can.

If we ever find a code for that water-logged Doppler, I promise that you will be the first to know.

Nicole Wocelka, CPM
Licensed Midwife and Chief Operating Officer at Larsen Billing Service

Is Your Practice ICD-10 Ready?

Larsen Billing Service is getting ready for ICD-10; is your practice ready for this giant change in charting, as well as coding?

We will be sending you resources for the next 8 months and we strongly encourage you to get the education you need to be ready for this giant change to the business of providing healthcare.

LBS is committed to helping you, but a simple ICD-9 code to ICD-10 conversion is impossible. You will need to do your part in choosing and charting the correct codes and procedures. For example:

Most pregnancy codes will have at least 4 ICD-10 codes for every 1 previous ICD-9 code, most of the time this will include information on the specific trimester in which you are billing. However, there are some complicated codes that have over 2,000 ICD-10 codes for 1 ICD-9 code.

Our point is not to scare you. We simply want to provide resources to you to help you understand that this will significantly change the amount of information you will need in order to fill out the superbill properly, and most practices will find that improvements will be needed to the client charting process as well.

While it is not possible for LBS to take responsibility for the content or any cost associated with the resources we share with you, we will only forward information from known and reputable sources. Please see below.

ICD-10 Resources for Providers
AAPC is offering a free 3-hour class to practices with less than 5 providers for ICD-10 compliance, details on whether or not membership is required were not available from AAPC at the time of publishing.

Registration form is available here: https://info.aapc.com/ICD-10DocumentationTrainingEM.html?mkt_tok=3RkMMJWWfF9wsRois6jMZKXonjHpfsX66uQlWKa0lMI%2F0ER3fOvrPUfGjI4ASsNhI%2BSLDwEYGJlv6SgFQ7PGMa5yyLgKUhk%3D

or you can call 844-825-1679


Here are some other options:



Client Education

FAQs about the Affordable Care Act

Doesn’t the Affordable Care Act require that Prenatal Care is covered at 100%?

Maternity Care is one of the 10 essential covered services; however the law does not define what maternity care includes, nor does it name the providers that provide it.

The Affordable Care Act means that midwives have to be paid, right?

The ACA has an additional Harkin Act that prevents insurance companies from discriminating against licensed providers (working within their scope) from participation. However, the Department of Health and Human Services has declined to define “participation” and there is absolutely no language in any part of the Harkin act or the ACA that guarantees that any licensed provider must be reimbursed. The definition of participation and levels of participation are left to the insurance companies to decide.

Why aren’t my lactation services being covered?

Lactation services are considered an essential covered service; however, discretion as to what credentials of the person providing the lactation services will be covered is left to the individual insurance company’s preference.

I’m out of network, what does the Affordable Care Act say about insurance reimbursement for me?

Absolutely nothing.  The ACA defines mandatory covered services, the removal of some restrictions in care, and the creation of an online marketplace to purchase care.  Out-of-network coverage is based on the individual plan purchased by the consumer.

Who is advocating for Midwives and their Clients?

Both the ACNM and AABC are working with legislators and lobbyists to advocate for the points of concern for Certified Nurse Midwives and Accredited Birth Centers.  We receive regular updates from the ACNM website and have attended seminars with their lobbyist.  Both Christine Romney and Nicole Wocelka of Larsen Billing Service volunteer on the Legislative Committee for AABC.

What is Larsen Billing Service doing about it?

The Affordable Care Act often leaves us with more questions than answers.  Over the past few years we have had a few providers ask us why we (LBS) are not sending out more information, lobbying and advocating for out-of-hospital midwives.

First, please understand as a small, niche-driven billing service, we are not equipped to affect change in Washington DC. Even if we were–it is not in your best interest for a for-profit company of primarily non-providers to do such things like define who is a midwife, define your scope, or speak on behalf of your profession and tradition.  What we can do and are doing is this:

  • We are testing and tracking reimbursement to discover if billing prenatal care separately from delivery pays at a higher rate or more often than billing global maternity. Some insurance companies automatically break out the prenatal portion of the global code and pay it separately.
  • We are working with interested parties to become contracted with insurance companies.
  • We are teaching topics in insurance billing, HIPAA, and the Affordable Care Act in midwifery conferences around the country and online.
  • We are keeping in contact with other stake-holders and non-physician providers on group efforts to advocate for compensation under the ACA.
  • We have offered our help and information to midwifery professional organizations.
  • When/if a benefits verification indicates a possible provider bias, we are asking for more information and appealing denied claims as necessary.


If you receive information from your professional groups or other organizations about developments regarding the ACA or any other laws, please send them to us (with references to statutes, acts, websites, or other resources) at nicole.wocelka@larsenbilling.com.

Client Education

What is included in Global OB care?

  • There are four Global OB Care Packages
  • Global billing is preferred in most cases
  • Billing outside of Global without charted reasons can be cause for audit
  • The Affordable Care Act may create an exception in some cases

Generally speaking, all Global OB Care Packages include routine antepartum care, admission to the facility (if applicable), routine labor management, delivery of fetus and placenta, episiotomy, forceps or vacuum delivery, perineal repair up to second degree, and routine postpartum care.

“CPT defines routine antepartum care as out-of-hospital service that includes initial and subsequent history, physical exams, recording of weight, blood pressure, fetal heart tones, routine chemical (dipstick) urinalysis, monthly visits up to 28 weeks gestation, biweekly visits between 28 and 36 weeks, and weekly visits until delivery.” Retrieved on January 14, 2014 from: http://www.supercoder.com/coding-newsletters/my-ob-gyn-coding-alert/whats-included-in-global-ob-care-packages-article

There are four Global OB Care Packages, simply defined as follows:

  1. 59400-routine antepartum care, vaginal delivery (with or without forceps/vacuum/episiotomy) and postpartum care.
  2. 59510-routine antepartum care, cesarean delivery, and postpartum care.
  3. 59610-routine antepartum care, vaginal delivery, and postpartum care, after previous cesarean delivery.
  4. 59618-routine antepartum care, cesarean delivery, and postpartum care, following attempted vaginal delivery after previous cesarean delivery.Obviously only numbers one and three are used in an out of hospital setting.

Why do they do it this way? Ultimately, the move to global codes is an attempt to both standardize and guarantee complete care for everyone. Furthermore, the Global OB Care Package was designed specifically to encourage women to seek early, routine prenatal care, and to not be penalized financially for taking advantage of every routine visit.

So when is something outside of global?

  • When an antepartum or postpartum visit is required outside of the usual schedule and includes a diagnosis other than a “V” code.
  • When another provider (outside of your practice) supplies services included in the definition of the Global Package.
  • When you treat a client/patient for something unrelated to her pregnancy and with a diagnosis to which pregnancy is incidental.

There are also global antepartum only codes. These are most commonly used in the case of an intrapartum transport. However with the Affordable Care Act requiring prenatal care as an essential benefit, some (non-grandfathered, non-self-pay) plans are paying global antepartum separately from delivery. (Keep in mind that the Affordable Care Act does not usually apply to Out-of-Network providers.) For this reason for the rest of 2014, Larsen Billing Service, when verifying benefits, will be asking if plans (in and out-of-network) follow the ACA prenatal coverage requirement. Larsen Billing Service will track the most effective way to bill the various insurance companies with regards to plans which require that we break up the billing.

As the provider rendering services, you are responsible for the codes that you choose. Larsen Billing Service relies on information provided by you to accurately submit claims to insurance.

As always, your Larsen Billing Service Billing Specialist is always here to answer your questions and it is our goal to work as partners in this ever-changing insurance world.