EMR/EHR Assessment

Under the 2009 regulations for Health Insurance Portability and Accountability Act (HIPAA) and Health Information and Technology for Economic and Clinical Health Act (HITECH), it was mandated that all hospitals and physician practices utilize a certified HER/EMR by 2015.

With the implementation of these systems, many facilities and practices have seen improved provider documentation, billing and coding as a result of:

• Quick phrases/Quick texts/Macros
• History of Present Illness (HPI), Review of System (ROS) and Physical Exam (PE) templates
• Drop down menus
• “No change since last visit” buttons
• Copy and Paste functions
• Coding calculators

Through recent documentation and coding audits, the Centers for Medicare and Medicaid Services (CMS), as well as other payers, have found the misuse and over use of these quick phrases, templates, copying and pasting that in some instances has led to what is now referred to as the “cloning” of medical records. This has resulted in a whole new area of audits.

In quite a few instances, it has also been found that the “coding calculators” within the EHR/EMR do not calculate the level of service correctly. This is not to say that they cannot be beneficial, but your practice needs to understand how they currently work and what the limitations are.