decisionhealth Newsletters, Part B News - 2014 Issue 2 (February)
Beware of EHR systems that allow non-clinicians to complete HPI
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Article Overview
This article addresses documentation compliance concerns in E/M office visits, focusing on how electronic health record workflows can involve ancillary staff in history-taking. It summarizes guidance from Medicare contractors and related payer policies, and it is relevant to physicians, non-physician practitioners, coders, billers, compliance staff, and practices using templated documentation.
Why This Topic Matters
The topic affects E/M documentation integrity, audit risk, and whether recorded history elements will be accepted when determining service level. Practices using EHR templates or scribes need to understand the broader compliance guidance discussed by Medicare contractors and auditors.
Article Sections
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Electronic health records
Introduces the documentation issue raised by EHR workflows and summarizes the compliance concern discussed in the article.
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Medicare contractor guidance
Reviews guidance from several Medicare contractors and related payer sources on who may document portions of the visit history and how those entries are viewed.
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Scribe workflow and documentation elements
Covers the use of ancillary staff as scribes and the documentation elements a practice should ensure are reflected in the record.
What You Will Learn
- How EHR templates can create compliance concerns in office visit documentation
- How Medicare contractor guidance addresses history-taking documentation
- What general documentation elements are emphasized when a scribe is involved
- Why practices are encouraged to review local MAC policies
Who Should Read This
- Physicians
- Non-physician practitioners
- Medical coders
- Medical billers
- Compliance officers
- Practice managers
- Auditors
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