EHR Articles and Resources

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Minor Procedures Get a Major Sting in the 2021 CERT Report

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

The 2021 Comprehensive Error Rate Testing report provides important lessons on exactly what errors are being found during chart reviews and how provider organizations can be proactive in their approach to quality documentation that not only supports the services provided to the patient but allows the providers to work in an environment of knowing what must be documented to support what they submit to the payer.

How to Reduce the Risk of Copy and Paste

by  Erica E. Remer, MD CCDS

Providers should never C&P (copy and paste) material they have not read nor vetted for accuracy. A young Jeopardy! champion died from bilateral pulmonary emboli following a colectomy in January 2021. Following his surgery, it was reported that the surgeon referred to “DVT/VTE Prophylaxis/Anticoagulation” and another note read, “already ordered.” “DVT...

What did I do today?


What did I do today?   Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...

A United Approach


A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...

HHS Proposes Significant Changes to Patient Access Rules

by  Wyn Staheli, Director of Content - innoviHealth

In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...

Health Information Exchange and Trusted Exchange Frameworks

by  Dugan Maddux, MD FACP

Despite progress in health IT, Health Information Exchange (HIE) remains squarely in toll booth mode, with gated stops and slowdowns that may or may not permit information to move forward. ...

Medicaid EHR Incentive

by  Wyn Staheli, Director of Content - innoviHealth

The Medicare and Medicaid incentive programs are different. The Medicare EHR incentive program has been incorporated into the new Quality Payment Program (QPP). However, providers may be unaware that there is still a Medicaid EHR incentive program. The time period for signing up for the Medicaid EHR incentive program ended in 2016. ...

What are the Rules for Safeguarding Patient Records?

by  ChiroCode™

Secure medical records is a broad topic that should be addressed in detail by all practices. There are multiple items to consider when meeting standards to best safeguard protected health information (PHI).

Meaningful Use Basics 

by  Karalyn

By Dr. Jeff Brown -Meaningful Use Mentor The big, bad word feared by many, “Meaningful Use,” simply means the performance of specific activities, known as Meaningful Use measures, with the aid of your certified EHR software. It’s not big and it’s not bad, and you definitely have nothing to fear. To begin, ...

Patient Electronic Access Tipsheet - Measure Compliance

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

MEASURE COMPLIANCE - Meeting the Patient Electronic Access Objective Starting in 2014, CMS requires that providers participating in both Stage 1 and Stage 2 of the EHR Incentive Programs must meet the Patient Electronic Access objective, which gives patients access to their health information in a timely manner. Providers participating in ...

Q & A: Does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology?

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Q: When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward ...

EHR Hardship Exemption

by  Karalyn

The following information is from the Centers for Medicare & Medicaid Services (CMS) regarding the Electronic Health Records (EHR) payment reduction hardship exemption.
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Do Minor Procedures Feel like Major Work? 

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

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