13-E&M Client Profile - March 2017.pdf - Client Profile...

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1 | P a g e Client Profile – E&M (eff. 03-2017) Practice Name: Click here to enter name Address: Click here to enter address. Phone Number: Click here to enter phone #. Fax Number : Click here to enter fax #. Website : Click here to enter website. Practice Contact and Title : Click here to enter contact information. Email Address : Click here to enter email address. Contracted Service Summary: Click here to enter information. Production Coding Auditing Services Helpline Services Logistics Documentation will be sent and returned via the following method: (please check) Fax Courier (Fed Ex-UPS) Which? Click here to enter text. Please provide your Project Manager the courier name & tracking # upon sending eBridge Sharefile Direct Access Method (please identify the EMR): Click here to enter text. Other (please explain): Click here to enter text. If we are preparing coding worksheets for data entry by your staff, please provide contact information for the staff member(s) receiving completed worksheets. Click here to enter contacts. If we are accessing your EMR system directly, you will need to provide a demonstration of your system to TCN. TCN will need to determine whether or not your system and required workflow will not slow down our coder’s production due to contracted production based invoicing. Depending upon your system and workflow requirements, a renegotiation of invoicing may need to be performed. TCN is mindful of turnaround times to accurately reflect month end and fiscal year end revenue. To assist us, please provide the date range of your fiscal year and when month end close occurs. Fiscal Year Click here to enter date span Month End Close Click here to enter text.
Do you have Rural Health Clinics? Yes No If YES, please provide TCN with a list of the names of the Providers and/or Clinics in which Rural Health would apply. If they apply to ALL listed providers/locations, please check “ALL”. ALL List: Click here to enter text. Are you a hospital- based clinic or physician owned clinic? Hospital-based clinic Physician owned clinic Do you have “Swing Bed” Skilled Nursing Facility coding? Yes Do you require any type of Facility E&M coding (Non Professional Fee coding)? Yes No No
2 | P a g e Does your practice bill for TeleHealth? Yes No Do you use scribes in your practice? Yes No If Yes, please provide an example of a scribed patient note. Attached Not attached due to Click here to enter text. Do any of your payers (including Workers’ Comp and Personal Injury) require use of external cause ICD-10 codes? Yes No If Yes, please provide the names of the payers. Click here to enter text. Please provide a sample of your documents for review prior to the contractual start date. This includes: Charge tickets Attached Not attached because these are not used Templates Attached Not attached because these are not used Dictation examples Attached Not attached due to Click here to enter text.

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