ED Coding & Reimbursement Alert - 2007 Issue 11
EHRs: Will Your E/M Notes Stand Up To EHR Audit Scrutiny?
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Article Overview
This article covers draft anti-fraud standards for electronic health records and the ways those standards could shape documentation practices, audit trail features, and compliance oversight. It is relevant to clinicians, coding and compliance staff, auditors, and EHR vendors who need to understand how documentation systems may be evaluated for fraud prevention and billing support. The article also discusses the role of RTI International, certification organizations, and the types of system safeguards and review functions the draft standards emphasize.
Why This Topic Matters
EHR design can affect documentation integrity, audit readiness, and billing support. Understanding proposed standards helps practices, vendors, and compliance teams anticipate documentation and security expectations.
Article Sections
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Draft anti-fraud standards for EHRs
Introduces proposed standards intended to reduce fraud risk in electronic health records and improve documentation integrity. Summarizes the general compliance and billing oversight concerns driving the proposal.
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Recommended EHR safeguards and audit functions
Describes broad categories of system safeguards, auditing capabilities, user verification, and access controls discussed by the expert panel. Also covers documentation traceability and patient access concepts at a high level.
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Next steps for the standards
Explains the general process for finalizing the standards and the role of certification organizations in adopting them. Notes the involvement of RTI and stakeholder review.
What You Will Learn
- Why draft EHR anti-fraud standards were proposed
- What kinds of documentation and audit features the standards address
- How the proposal relates to E/M documentation support and EHR certification
- What general implementation steps may follow if the standards are finalized
Who Should Read This
- Physicians and other clinicians
- Medical coders and coding auditors
- Compliance and revenue integrity staff
- EHR software vendors
- Healthcare administrators
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