E/M Coding Alert - 2013 Issue 2
EMR Strategies: Know When And Where To Use Attestations In Your ED Charts To Stay Out Of Trouble
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Article Overview
This piece focuses on emergency department EMR documentation practices, with emphasis on when attestations may be used to support elements of E/M charting and special documentation circumstances involving residents, teaching physicians, scribes, and nonphysician practitioners. It also discusses audit and compliance concerns tied to generic or inaccurate attestation language. The article is aimed at ED coders, physicians, and compliance staff who need to understand documentation expectations in electronic records.
Why This Topic Matters
Attestations can streamline documentation, but improper use can create audit risk and undermine support for reported services. Understanding the documentation context is important for maintaining compliance in ED coding workflows.
Article Sections
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Follow This E/M Attestation Model
Overview of how attestations may relate to major elements of emergency department E/M documentation. The section addresses documentation contexts commonly discussed in EMR workflows.
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Don’t Forget Special Circumstances For Residents, Scribes and NPPs
Discussion of documentation situations involving teaching physicians, residents, procedures, interpretations, and scribe-assisted records. The section also covers compliance considerations for shared services and related charting scenarios.
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Watch Out: Attestations Can Help, But They Can Also Hurt
Examples of documentation pitfalls and audit concerns associated with attestation use in ED charts. The section emphasizes risks from inaccurate, generic, or mismatched documentation.
What You Will Learn
- How attestations fit into emergency department electronic documentation
- Which documentation areas are commonly discussed in relation to attestations
- What special documentation scenarios arise with residents, teaching physicians, scribes, and NPPs
- Why audit review can be affected by inaccurate or overly generic attestations
- How attestation practices relate to compliance concerns in ED charting
Who Should Read This
- Emergency department coders
- Emergency department physicians
- Compliance staff
- Health information management professionals
- Billing and coding auditors
Codes Discussed
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