tci Medicare Compliance & Reimbursement - 2007 Issue 11

EHRs: Will Your E/M Notes Stand Up To EHR Audit Scrutiny?

Beware: Too much cutting and pasting could wound you.Your electronic health records (EHRs) could soon need an upgrade. RTI International (RTI) just released a draft version of anti-fraud standards for EHRs. The standards could put more pressure on doctors to support evaluation & management (E/M) levels in documentation. RTI convened a panel of experts to suggest ways that EHRs could guard against fraud and incorrect billing. The experts said EHRs should:· Make sure cut-and-pasted documentation keeps the original time-and-date stamp from the records it was cut from (but if the doctor cuts and pastes from one patient's record...

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