decisionhealth Newsletters, Coder Pink Sheets - 2014 Issue 2 (February)
Understanding E/M: Beware of EHR systems that allow non-clinicians to complete HPI
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Article Overview
This article explains current documentation and compliance concerns affecting E/M office visits when electronic health record templates and ancillary staff are involved in collecting visit history. It is aimed at physicians, non-physician practitioners, coders, compliance staff, and practice managers who need to understand how Medicare contractors and other oversight bodies are viewing E/M documentation, including history-taking practices and risks tied to cloned or copy-pasted notes.
Why This Topic Matters
Accurate E/M documentation is central to proper claim support, audit readiness, and avoiding denials or post-payment scrutiny. The article highlights why practices using EHR templates and scribe workflows should review their documentation processes against payer and contractor expectations.
Article Sections
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HPI documentation and ancillary staff involvement
Explains concerns about who may document parts of the visit history and why EHR templates can create compliance risk when multiple staff members contribute to the record.
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MAC and payer guidance
Summarizes guidance and positions from Medicare contractors and other payers regarding documentation of office visit history and related review processes.
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Scribe workflows and required record elements
Describes documentation oversight considerations when a scribe is used and outlines the kinds of record elements practices are told to verify.
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More EHR oversight in your future
Covers increased scrutiny of EHR-generated notes, including concerns about copied content, overdocumentation, and template-driven inconsistencies.
What You Will Learn
- How E/M documentation oversight relates to EHR template use
- Why history-taking workflows can raise compliance concerns
- What kinds of note-review issues auditors are focusing on
- How practices may need to monitor cloned or copied documentation
- Which types of organizations are issuing guidance on E/M documentation
Who Should Read This
- Physicians
- Non-physician practitioners
- Medical coders
- Compliance officers
- Practice managers
- Billing staff
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