Obstetrics and Gynaecology – Accurate Documentation Indispensable for Medicaid

Obstetrics and Gynaecology – Accurate Documentation Indispensable for Medicaid

With professional medical transcription services to provide documentation support, OB-GYN physicians can focus on providing quality care to the patients.

MTS Transcription Services United States

When it comes to timely documentation, most medical specialties including Obstetrics and Gynaecology find medical transcription services a practical option. Obstetrics and gynaecology healthcare practitioners often face the challenge of balancing the very important clinical documentation requirements while spending enough time with their patients. Error-free and comprehensive documentation is necessary for Medicaid reimbursement for OB-GYN services. Medicaid reimburses pre-natal care, deliveries, and postpartum care as individual services. It is easier for physicians to dictate their notes and have the transcription provider create transcripts because there are certain specific facts that must be clearly documented for Medicaid. For instance, visits are restricted to 20 per pregnancy, but for high-risk obstetrical visits this limitation is waived. So the provider has to clearly state in the medical record that the pregnancy is complicated and frequent visits are necessary. The documentation supporting the need for increased visits must be maintained in the physician’s files and is subject to retrospective review.

OB-GYN operative reports are very challenging and must be accurate with details of the procedures performed. Typically, an operative report will have: •

Title of the operation

•

Pre-operative diagnosis

•

Post-operative diagnosis

•

Anesthesia

•

Estimated blood loss

•

Description of the procedure

Apart from operative reports, physicians have to also maintain the following reports to ensure complete and comprehensive documentation.

•

History and Physicals

•

Chart notes

•

Progress reports

•

Emergency room reports

•

X-ray and lab reports

•

Discharge summaries

Now, EHR has become part and parcel of medical practices and practitioners who want to continue

the

dictation

transcription

model

can

opt

for

EHR-integrated

medical

transcription service where they can enjoy the benefits of both transcription and EHR. With increasing implementation of EHR, medical transcriptionists now function more as medical editors and healthcare documentation specialists.

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(800) 670 2809

While providers, with EHR implementation and accurate documentation with the support of medical transcription companies , strive to meet Medicaid as well as other health insurance requirements, are insurers ensuring timely and appropriate care for pregnant women? Consider the case of Medicaid in the light of a news item regarding Alabama Medicaid. In this state, pregnant women have to wait for four to eight weeks to visit their doctor.

According to doctors and

patients, Alabama’s complex maternity Medicaid process can mean some moms don’t get their first OB-GYN appointment until they are into their second trimester or 13 weeks or more into their pregnancy.

Medicaid covers almost half of the births in Alabama.

Majority of the obstetricians prefer to see their patients about four or eight weeks after a woman would get a positive result. The percentage of women who get prenatal care has dropped in recent decades according to the Alabama Department of Public Health, from 79 percent in 2003 to 75 percent in 2015. This shows that most of the women in rural Alabama receive inadequate prenatal care.

Most OB--GYN offices require a patient to have Medicaid or insurance before consulting the doctor for prenatal appointment. Women can apply for pregnancy Medicaid in person at the county healthcare department or apply online. They can also contact the Medicaid outreach worker and obtain assistance with the paperwork. Medicaid takes 45 days to approve and now the extended wait time between the application and actually seeing the patient is increasing. Due to this issue, doctors often tell patients to visit them even without Medicaid. Around 16 counties in Alabama do not even have Medicaid Maternity Care Program. In October this year, Medicaid plans to place all of its maternity care management under contracted Regional Care Organizations (RCO). One of the objectives of this RCO system is to get 80% of the women to have their first prenatal visit during their first trimester.

Timely and appropriate OB-GYN services are vital for to-be mothers, and these services have to be also documented in a timely manner. Outsourcing medical transcription will no doubt, prove very supportive for busy obstetricians and gynaecologists.

www.medicaltranscriptionservicecompany.com

(800) 670 2809