decisionhealth Newsletters, Part B News - 2012 Issue 6 (June)
Audit your E/M documentation – particularly on EHR – before private payer reviews
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Article Overview
This article explains why practices are paying closer attention to evaluation and management documentation ahead of private payer reviews, with emphasis on internal audit planning, electronic health record documentation issues, and broader billing risk areas. It is aimed at coding professionals, practice managers, auditors, and clinicians who review documentation quality and want to understand the general types of compliance and education topics raised by payer oversight.
Why This Topic Matters
It helps readers understand how auditing trends, EHR documentation patterns, and broader billing risk areas can affect practice compliance and payer attention without assuming that every high-level claim is improper.
Article Sections
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E/M documentation
Introduces concerns about higher-level evaluation and management billing and the need for internal review before payer scrutiny. It frames the article around documentation quality and audit readiness.
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Design your E/M audit protocol
Outlines general approaches for building an internal audit process and responding to outlier billing patterns. It also touches on education, documentation review, and related billing oversight areas.
What You Will Learn
- Why practices may want to review evaluation and management documentation internally
- How electronic health record workflows can affect documentation review
- What broad patterns may prompt closer auditing of providers
- Why broader billing risk areas may be included in audit planning
Who Should Read This
- Medical coders
- Coding auditors
- Practice managers
- Physician practices
- Compliance staff
- Billing supervisors
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