decisionhealth Newsletters, Coder Pink Sheets - 2020 Issue 12 (December)
Compliance: Your EHR is not to blame for medical direction errors
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Article Overview
This article addresses a compliance question raised in the context of anesthesia coding and electronic health records. It discusses whether EHR software creates liability when documentation workflows interfere with closing a case, and it frames the issue as one of local practice management, documentation handling, and vendor coordination. The piece is aimed at anesthesia professionals, coding staff, and compliance-minded practice administrators.
Why This Topic Matters
It helps readers understand that documentation workflow problems can affect compliance and payment risk, even when the EHR itself is not considered the responsible party. The article is relevant for practices trying to manage anesthesia documentation processes and reduce risk tied to incomplete or problematic records.
What You Will Learn
- How EHR workflow issues can affect anesthesia documentation processes
- Why documentation responsibility may rest with the practice rather than the software vendor
- How compliance concerns can arise from case-closing and record-completion workflows
- Why local documentation work-arounds may be needed in some settings
Who Should Read This
- Anesthesia providers
- Medical coders
- Compliance staff
- Practice administrators
- Billing staff
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