ED Coding & Reimbursement Alert - 2013 Issue 2
Mythbuster: Debunk 3 EHR Myths That Could Be Setting You Up for Payer Audits
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Article Overview
This article is a practical coding and documentation review for E/M services in the context of electronic health records. It explains why certain EHR features can create compliance risks, what general documentation elements matter for supporting visit levels, and why payer review concerns arise when documentation does not align with medical necessity and E/M reporting requirements. The content is aimed at coders, billers, auditors, and clinicians who document office visits in an EHR environment.
Why This Topic Matters
EHR systems can streamline documentation, but they can also encourage incomplete, overbuilt, or unsupported records that increase audit exposure and jeopardize payment.
Article Sections
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Myth 1: Exam Documentation Will Carry Over for Follow-Up Visits
Discusses how EHR carryover can affect documentation for established patients and follow-up encounters. The section focuses on general E/M documentation concerns and recordkeeping expectations.
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Myth 2: EHR’s Calculation of Time Spent Qualifies You to Code Based on Time
Reviews time-based E/M reporting in the context of EHR-generated time totals. The section covers the broad documentation elements associated with time-based coding and visit counseling/care coordination.
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Myth 3: You Should Use the EHR’s Code Selection in Every Case
Addresses EHR-generated code suggestions and the relationship between documentation, medical necessity, and code selection. The section focuses on general payer expectations for E/M level support.
What You Will Learn
- How EHR documentation features can affect office visit coding and audit risk
- Why follow-up documentation practices matter in E/M encounters
- What general elements are associated with time-based E/M reporting
- Why EHR code suggestions should be reviewed critically
- How medical necessity factors into E/M code selection
Who Should Read This
- Medical coders
- Billers
- Compliance staff
- Clinical documentation specialists
- Physicians and other clinicians
- Practice managers
- Auditors
Codes Discussed
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