Outpatient Facility Coding Alert - 2004 Issue 17
Electronic Medical Records: Beware "Canned Documentation," Coding By Numbers, With EMRs
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Article Overview
This article examines the practical and compliance-related concerns that can arise when a practice adopts an electronic medical record (EMR) system. It focuses on documentation integrity, audit risk, medical necessity, and how EMRs may affect coding practices and liability. The piece is aimed at coders, auditors, physicians, and practice managers evaluating EMR-driven workflow changes.
Why This Topic Matters
EMR systems can affect how services are documented, reviewed, and billed, which has implications for audit defensibility, compliance, and malpractice exposure. Understanding these risks helps practices evaluate EMR workflows without assuming that more automated documentation automatically supports higher-level coding.
What You Will Learn
- The compliance concerns associated with EMR-based documentation workflows
- How documentation practices can affect audit review and medical necessity questions
- Why automated or carried-forward content may create liability concerns
- How EMR implementation may influence coding and billing practices in a practice setting
Who Should Read This
- Medical coders
- Coding auditors
- Physicians
- Practice managers
- Compliance staff
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