decisionhealth Newsletters, Coder Pink Sheets - 2009 Issue 5 (May)
Avoid EMR compliance pitfalls
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Article Overview
This article explains why electronic medical records can create compliance issues if they are not implemented and managed carefully. It is aimed at ophthalmology coders, physicians, and practice staff involved in EMR selection, documentation, and coding compliance. The discussion covers common risk areas such as default settings, templates, point-and-click documentation, and record cloning, along with references to Medicare-related guidance and oversight concerns.
Why This Topic Matters
EMR systems can affect whether documentation accurately supports the services billed, so understanding the compliance risks helps practices avoid inaccurate records and potential coding problems.
What You Will Learn
- How EMR design and workflow can affect documentation compliance
- Why coder involvement matters during EMR selection and implementation
- What types of EMR documentation practices raise compliance concerns
- How Medicare-related guidance has addressed EMR documentation risks
- Why accurate records must reflect the work actually performed
Who Should Read This
- Ophthalmology coders
- Physicians
- Medical office staff
- Compliance personnel
- Practice administrators
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