Compliance: Beware: 'Audit-Proof' EHRs Don't Exist, Experts Say

Why This Topic Matters

It helps readers understand the limits of automated EHR coding support and the importance of validating documentation before submitting higher-level evaluation and management claims.

Article Sections

1. Overview

   Introduces the compliance concern involving automated EHR-assisted coding and the need to verify that documentation supports billed services.

2. Medical necessity and E/M documentation

   Discusses how documentation, history, and examination findings relate to evaluation and management level selection and audit risk.

3. Self-audit your physician's records

   Describes a chart review approach for checking whether the recorded complaint and diagnoses align with the reported level of service.

4. Your practice is responsible for your submitted charges

   Addresses provider and practice accountability for claims, including contract considerations with EHR vendors.