Medicare Compliance & Reimbursement - 2010 Issue 44
Electronic Health Records: Avoid These EHR Coding Pitfalls -- And Collect Your Share of the $44,000 Per-Physician Federal Incentive Bonus
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Article Overview
This article explains how electronic health records can affect practice operations, documentation quality, and coding compliance. It is aimed at physicians, coders, and practice managers evaluating EHR adoption or trying to avoid documentation and workflow problems. The discussion covers general EHR benefits, federal incentive programs, concerns about system-generated documentation prompts, avoiding copied records, and integrating EHRs with practice management software.
Why This Topic Matters
EHR systems can improve access to information and streamline workflows, but poor setup or overreliance on software prompts can create compliance and documentation risks. Understanding the article helps practices evaluate whether their EHR supports accurate records, appropriate billing, and operational fit.
Article Sections
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Determine What an EHR Would Mean to Your Practice
Introduces the role of electronic health records in practice operations and patient information management. Covers general benefits, access to information, and federal incentive context.
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Don't Let EHR Do the Coding for You
Discusses concerns about software prompts influencing documentation and coding workflow. Emphasizes the importance of provider judgment and complete documentation.
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Avoid 'Canned' Documentation
Addresses risks associated with carrying over information between visits. Explains why repetitive documentation patterns can create compliance concerns.
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Know How the EHR Will Blend With Your Current Software
Covers integration between EHR systems and practice management software. Focuses on workflow coordination, vendor communication, and division of system responsibilities.
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The EHR Should Work for You -- Not the Other Way Around
Summarizes the importance of selecting a system that matches practice needs. Highlights customization and usability as major considerations.
What You Will Learn
- How EHR adoption can affect practice workflow and documentation processes
- What general compliance concerns can arise from system-generated documentation prompts
- Why copied or repeated documentation can be problematic
- How EHR and practice management systems may need to work together
- What factors matter when evaluating whether an EHR fits a practice
Who Should Read This
- Physicians
- Medical coders
- Practice managers
- Billing staff
- Compliance personnel
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