BC Advantage - 2012 Issue 11
Muddy Roads Ahead for Electronic Health Record Documentation?
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Article Overview
This article discusses documentation quality issues found in electronic health records during baseline audits and compliance reviews for physician practices. It focuses on how audit findings, system-generated charting problems, and incomplete visit documentation can affect Evaluation and Management record review and medical necessity assessment. The piece is aimed at physicians, coders, auditors, practice managers, and compliance staff who support office documentation and audit preparedness.
Why This Topic Matters
Documentation problems in EHRs can affect audit outcomes, compliance risk, and the defensibility of billed services. Understanding the article helps readers recognize the kinds of record-review concerns that may arise in physician office compliance programs and external audits.
Article Sections
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Baseline audits and compliance preparation
Introduces the need for baseline audits in physician practices and places the discussion in the context of compliance program readiness, audit activity, and documentation review.
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EHR documentation problems observed in audits
Describes common issues seen in electronic records, including workflow-related documentation concerns and charting patterns that can complicate audit review.
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Examples of documentation and system-related issues
Summarizes several broad categories of EHR and documentation problems identified during audit assignments, including internal system behavior and incomplete charting elements.
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Impact on Evaluation and Management review
Explains how documentation issues may affect the review of office visit records and the assessment of service levels during compliance and audit processes.
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Extended HPI and status of chronic conditions
Discusses documentation expectations related to history-taking and the need for status information when chronic or inactive conditions are referenced.
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CMS guidance and reference resources
Points readers to CMS-related guidance and external educational resources used to support office documentation review and provider education.
What You Will Learn
- How baseline audits are used in physician office compliance preparation
- Which broad types of EHR documentation issues may appear during audits
- Why documentation completeness matters for medical necessity review
- How history and examination documentation can affect audit outcomes
- Where CMS-oriented resources may be used in provider education
Who Should Read This
- Physicians
- Medical coders
- Coding auditors
- Compliance officers
- Practice managers
- Medical office staff
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