Top 3 EHR Documentation Myths

 

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English: Social Security Administration Office of Inspector General Seal. (Photo credit: Wikipedia)

Few healthcare providers realize how much paperwork will play an integral role in obtaining correct reimbursement as well as offering the best patient health care.

Without correct help and advice, your physicians tend to make several assumptions regarding your organization’s EHR system that may undermine the caliber of their documentation.

Here are three typical paperwork myths that healthcare practices need to look out for and target:

 

1. Our system automatically calculates our “evaluation and management” levels.

This is correct to some extent because EHRs in most cases estimate a visit’s E&M amount, however, this computation is normally determined by data within the drop down menus and check boxes. Many providers don’t use these menus, and thus the E&M amount may not be correct if free text is used.

Ideally, a practice should create an EHR template with certain check boxes and menus to prevent the necessity for manual wording. In addition, providers should create precise E&M levels instead of depending on any Electronic health record or a coder to level a visit.

2. We just use a similar diagnosis.

Some healthcare providers often choose a diagnosis from the Electronic health record which is not the perfect match. This is due to some templates being out-of-date or not specific.

Choosing the wrong diagnosis code can put providers at risk for incorrect compensation as well as your patients in danger of an incorrect diagnosis.

Furthermore, with the move to ICD-10 on October 1, 2014, it’s more crucial to document an accurate diagnosis. ICD-10 will demand a lot more accuracy from providers, and repayment might be affected if not.

3. We can use last month’s chart notes because it’s the same visit.

Heathcare entities may like the reduced effort related to cloning chart notes from the prior visit, however doing this might put you in danger of an examination or a denied claim in the event the records are too homogeneous.

Therefore, any practice may well be more apt to be audited when your documentation isn’t distinct enough for each date of service.

 

 

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