EMR EHR Assessment

EMR/EHR Assessment

HIPAA Regulations

Under the 2009 Health Insurance Portability and Accountability Act (HIPAA) and the Health Information and Technology for Economic and Clinical Health Act (HITECH) regulations it has been mandated that all hospitals and physician practices be utilizing a certified HER/EMR by 2015. Many hospitals and practices have already implemented the EHR’s/EMR’s.

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 lead to what they are now calling the “cloning” of medical records. This has given way to a whole new area of audits.

In quite a few instances it has also been found that the “coding calculators” within the EHR/EMR does not calculate to 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.