decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 4 (April)
Avoid EMR compliance pitfalls
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Article Overview
This article discusses compliance risks associated with electronic medical record (EMR) implementation and use, especially where system defaults, templates, favorites lists, auto-populated fields, and cloned documentation may affect coding and documentation accuracy. It is aimed at coding professionals and healthcare organizations evaluating EMR workflows, and it highlights the importance of aligning system design and provider documentation with general coding and compliance expectations.
Why This Topic Matters
EMR features can unintentionally create documentation patterns that do not accurately reflect patient-specific services, making it important for coding teams to recognize compliance risks during selection and implementation.
What You Will Learn
- Common EMR workflow features that can create documentation and compliance concerns
- Why coding staff should be involved in EMR vendor selection and implementation
- How automated documentation behaviors can affect record integrity and compliance review
- The role of external guidance and Medicare-related bulletins in EMR compliance awareness
Who Should Read This
- Coding managers
- Medical coders
- Compliance staff
- Healthcare administrators
- Physicians using EMRs
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