Transcription and Coding
Transcription: From Dictation To Transcription, Next-Day

In today’s increasingly cost-sensitive healthcare environment, the maxim “If not documented, not done” serves as a stark reminder that the accurate documentation of services rendered is essential to compensation. And the first step in this process is transcription—the careful conversion of clinical notes on a care episode into a report that is easily and effectively interpreted by a coding professional.

GENASCIS™ offers next-day documentation turnaround of providers’ clinical dictation using our state-of-the-art telecommunication system and Web-based portal. Users simply call in to dictate notes via our toll-free number or upload a pre-recorded audio file to the GENASCIS Transcription Portal.

Transcription Methodology

GENASCIS accepts dictation 24/7. Any dictation received prior to 5:00PM (Pacific Time) is transcribed and returned the following business day. History and Physicals received prior to 11:00PM (Pacific Time) and designated as urgent are transcribed and delivered to the facility prior to business hours the following morning.

Each facility and provider is assigned a unique ID. At the onset of the dictation process, the system prompts the provider for the facility ID, their personal ID and finally patient information, such as medical record number.

Dictation is transcribed into Microsoft® Word and made available to registered users via the GENASCIS Transcription Portal.

Transcription Portal

Our Web-based Transcription Portal not only handles the intake of dictation; it also enables physicians with security privileges to view, edit and approve transcribed documents with legally-binding electronic signatures, as well as review text and voice files simultaneously. For security purposes, a detailed signature audit trail with date and time stamp is maintained.

Once logged in, physicians are presented with a personalized dashboard that summarizes pending transcription ready for their review and authentication. Physicians even have the ability to “batch” sign/approve transcribed reports in real-time, and download or fax them directly to the appropriate parties.

Coding: The Best Clinical Coders On The Planet

No function in the ASC revenue cycle impacts your bottom line more than coding. Coding is art and science that requires both interpretive skill and analytical rigor. Assigning the appropriate codes to any encounter is a complex task with an untold number of variables involved. These variables can be a function of surgical technique, the size of incision, the type of anesthesia, and the list goes on. And that doesn’t even take into account other factors such as CMS mandates, AMA guidelines and local contractual issues.

GENASCIS can help your facility turn what has traditionally been an industry bottleneck into a decided competitive advantage. Our sizeable team of well-trained, high-caliber certified coders simply has no peer. Doctors, nurses and other medical professionals comprise a large portion of our clinically educated coding staff. Providing cost-effective and accurate coding for ASCs, surgical hospitals and specialty physician practices, as well as Medicare-compliant coding, these coding specialists will maximize your reimbursement potential and improve cash flow.

Coding Platform

In addition to thoroughly understanding and remaining current with a wealth of ASC- and specialty-specific clinical procedures and terminology, our coding experts faithfully adhere to documentation and coding guidelines issued by CMS, including CCI (correct coding initiative) edits; however, should there be a guideline issued by the AMA (American Medical Association) in conflict with CCI edits, the AMA guideline supersedes to accommodate third party payors.

In an ASC setting, the CPT code determines reimbursement, while the ICD-9 diagnosis code establishes medical necessity. Inextricably linked, the reconciliation of each is a top priority for our coding experts.

Coding Process

The coding process starts with a certified coder reading the entire operative report and abstracting appropriate CPT codes. The procedures dictated under “Procedure Performed” in an operative report are used as guidelines. The final documentation to issue a CPT code must reside within the narrative of the operative report. If a procedure is listed yet not supported in the body of the report, the CPT code will not be issued.

The reverse is also true. If a procedure is not listed under “Procedure Performed” but is documented in the narrative of the operative report, it will be abstracted, coded and submitted for billing.

The coder also evaluates the operative report for all bundling edits and applicable modifiers.

To establish medical necessity, appropriate ICD-9 diagnosis codes linking to the CPT must be issued. The guideline for this documentation varies slightly from the CPT requirement. The primary source of diagnosis codes in an operative report is the “Postoperative Diagnosis.” If this is insufficient, anything documented in the narrative or “Preoperative Diagnosis” may be used to help establish the medical necessity of the procedure. In an ASC setting, any diagnosis dictated as “rule out”, “probable” or “may be” cannot be used to support the procedure. Only a definitive diagnosis may be reported. If a definitive diagnosis is not available or established, the coder will attempt to establish the medical necessity via reporting of signs and symptoms.

In brief, the op report is read in its entirety. Following all guidelines set forth by CMS and AMA, the coder must strategize to ensure: (1) all possible CPT codes are captured, (2) supporting ICD-9 diagnosis codes are abstracted, (3) appropriate modifiers are applied and (4) all of this documentation is submitted for billing.

TRANSCRIPTION

  • Peace-of-mind knowing your transcription will return within 24 hours
  • Keep your paperwork flowing smoothly and avoid coding delays
  • Access a transcription team with ASC-specific knowledge that specializes in surgical procedures
  • Easy record processing and maintenance made possible by standardized reporting format (Microsoft Word)
  • Transcription experts’ immersion in latest clinical terminology improves report accuracy
  • Accurate transcription that transcends language barriers
  • Coding efficiency is optimized by unsurpassed report integrity
  • Realize the enhanced speed and security of transcription services that embrace technological innovation
  • More efficient transcription authorization through dashboard-driven transcription portal
  • No facility investment in technology or staff

CODING

  • Erroneous or incomplete coding is minimized, while first-time acceptance is enhanced
  • Reimbursement is maximized and payment processing time reduced through quality control processes
  • Delegate the important task of regulatory compliance and focus on patient care
  • Affordable access to a team of certified coders with diverse, clinical expertise that is devoted to remaining current with coding trends and mandates
  • No training or infrastructure costs for the facility
  • Expedite the transition from coding to billing when both services are handled by GENASCIS
  • Avoid the task of hiring, developing and retaining skilled coders

TRANSCRIPTION

  • Next-day turnaround of transcription with 100% delivery record
  • Accepting dictation around-the-clock
  • Transcription for ASCs and all types of specialty physician practices
  • Telephone-based dictation acceptance system
  • Web-based transcription portal for documentation review with electronic signature, audit trail and direct faxing capabilities
  • Computer-generated reports (MS Word) and reconciliation information
  • Continuous education of transcription experts relative to the ever-evolving medical lexicon
  • Particularly adept at understanding speech patterns as well as various accents and dialects
  • Report integrity that meets and exceeds industry standards
  • State-of-the-art technology, communications processes and secure storage of text and audio files for digital integrity, safety and security
  • Seamless integration of transcription and coding

CODING

  • Near-encyclopedic knowledge of ASC coding processes and procedures
  • Coding qualified and its viability examined prior to claim processing
  • Constant monitoring of most recent regulatory requirements and compliance guidelines
  • Certified coders with clinical backgrounds providing ASC, multi-specialty and Medicare coding
  • Commitment to on-going education initiatives among our coding experts, including the seminars, tradeshows, training courses and independent study of the most recent coding mandates
  • Part of a seamlessly integrated revenue cycle solution from the industry’s only single-source resource