General Surgery Coding Alert - 2004 Issue 21
Medical Records: Beware Of Coding By Numbers When Using EMRs
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Article Overview
This article examines how electronic medical records can affect documentation quality, audit risk, and the ability to support billed services. It is aimed at coders, auditors, and practice staff evaluating how EMR features influence history, examination, medical decision making, and medical necessity. The discussion focuses on general guidance about documentation reliability, carried-forward entries, customized prompts, and why more documentation does not always support higher-level billing.
Why This Topic Matters
EMR systems can change how clinical notes are created and reviewed, which affects compliance, malpractice exposure, and whether billed services are supported by the record. Understanding these risks helps practices avoid overdocumentation, inaccurate carry-forward content, and audit problems.
What You Will Learn
- How EMR workflows can influence documentation quality
- Why carried-forward information can create compliance and liability concerns
- How medical necessity affects whether documentation supports a billed service
- Why customized prompts differ from canned documentation
- How auditors may evaluate changes in documentation patterns after EMR adoption
Who Should Read This
- Medical coders
- Medical auditors
- Compliance staff
- Practice managers
- Physicians
- Billing staff
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