Outpatient Facility Coding Alert - 2011 Issue 11
Electronic Health Records: 'Audit-Proof' EHRs Don't Exist, Experts Say
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Article Overview
This article discusses the limits of EHR-based coding tools and why practices still need to verify that selected evaluation and management codes are supported by the medical record and the patient’s documented condition. It addresses audit risk, payer review, self-auditing of charts, and vendor contract considerations. The piece is aimed at physicians, practice managers, coders, and compliance staff who oversee documentation and billing quality.
Why This Topic Matters
It highlights common documentation and billing risks when practices rely too heavily on automated EHR coding outputs, and it explains why internal review and documentation validation remain essential for compliance.
What You Will Learn
- Why automated EHR coding assistance does not replace documentation review
- How medical necessity relates to evaluation and management reporting
- Why payer audits may focus on unusual coding patterns
- How internal chart review can help identify unsupported billing patterns
- What to consider when contracting with an EHR vendor
Who Should Read This
- Physicians
- Practice managers
- Medical coders
- Compliance staff
- Billing staff
Codes Discussed
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