E/M Coding Alert - 2012 Issue 37
Part B Mythbuster: Don't Buy Into These 3 Common EHR Fallacies
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Article Overview
This Find-A-Code article addresses three frequent EHR-related misconceptions that can affect documentation quality and claim support for Part B services. It is aimed at coders, billers, and clinical staff who rely on electronic health records for evaluation and management documentation. The article discusses documentation carryover, time-based reporting, and EHR-generated code suggestions in the context of Medicare and CPT-guided office visit coding.
Why This Topic Matters
EHR shortcuts can create documentation gaps or overreliance on automated prompts, which may affect audit risk and the defensibility of E/M claims. Understanding the limits of what an EHR can supply helps practices document more consistently and review coding support more carefully.
Article Sections
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Myth 1: Exam Documentation Will Carry Over for Follow-Up Visits
Discusses how EHR documentation may carry forward certain history elements and why follow-up encounter documentation still needs appropriate current-record support. The section focuses on documentation continuity and audit exposure in E/M records.
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Myth 2: EHR's Calculation of Time Spent Qualifies You to Code Based on Time
Reviews time tracking within EHR systems and the broader requirements involved in reporting services based on time. The section explains what kinds of encounter documentation are relevant to time-based reporting.
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Myth 3: You Should Use the EHR's Code Selection in Every Case
Explores automated EHR code suggestions and the need for clinician review before finalizing an E/M code. The section addresses the relationship between documentation, medical necessity, and code selection support.
What You Will Learn
- How EHR documentation can affect support for E/M claims
- Why automated time totals in an EHR do not, by themselves, determine coding
- How to think about EHR-generated code suggestions as part of a coding workflow
- Why current documentation and medical necessity remain important in Part B services
Who Should Read This
- Medical coders
- Medical billers
- Practice managers
- Physicians
- Clinical documentation staff
- Compliance staff
Codes Discussed
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