Effective Communication In A Medical Office

Completeness the message must contain all necessary information. Clarity The message must be free from obscurity and ambiguity. Conciseness The message must not include any unnecessary information. Courtesy The message must be respectful and considerate of others. Cohesiveness The message must be organized and logical. Your confidence and self-esteem can positively affect your success in the medical field. The way you represent yourself is the way others will see you.

The communication cycle consists of giving and receiving information. As you interact with patients and their families, you will be responsible for giving information and ensuring that the patient understands what you, the physician, and other members of the staff have communicated. You also will be responsible for receiving information from the patient. It is important that we promotes patients' comfort and well-being. Positive communication is essential in the medical office such as:

• Being friendly, warm, and attentive

• Verbalizing your concern for patients

• Encouraging patients to ask questions

• Asking patients to repeat your instructions in order to make sure they understand

• Looking directly at patients when

you speak to them
• Smiling naturally
• Speaking slowly and clearly
• Listening carefully
In addition "Most people do not intend to communicate negatively; however, some communication practices have a negative effect on others, always have a positive attitude when dealing with patients and people on the job.
Part 2: Discuss the use of E/M codes and some common practice pitfalls that occur in the coding of E/M code services
"A number of EHR (Electronic Health Record) products feature tools that automate the process of determining the E&M (evaluation and management) code for an office visit.

When these tools are properly designed and used appropriately, they result in very accurate coding supported by thorough documentation. This can result in very significant and completely justified increases in revenue, not uncommonly reaching tens of thousands of dollars. This has attracted the interest of auditors, however, including the Office of the Inspector General (the body that performs audits for CMS). There is no certification or formal evaluation process for EHR E&M coding tools. Regardless of what code is suggested by an EHR, the clinician is ultimately responsible for the code submitted for

reimbursement."
Physicians who are using automated E&M coding tools should follow these three steps to ensure the codes they submit are accurate:
1. Challenge your vendor to show you how the coding tools comply with published E/M coding guidelines. Most auditors use the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services (these can be downloaded from the CMS website: http://www.cms.gov/. The vendor should be able to tell you exactly how the tools capture E&M related information from each section of the note, including the HPI, Past Medical History, Family History, Social History, Review of Systems, Physical Examination, Assessment and Plan. They should also be able to show you how medical complexity and the overall score is to determined from this information. The demonstration should also show how time can be used to determine the E&M code in place of documentation when appropriate".