The benefits of Electronic Medical Records (EMRs) have been heavily promoted since 2004. Benefits include improvements to medical record storage, retrieval, and modification in addition to cost reductions for medical record storage and staff.
Potential benefits ascribed to EMR use that are yet to be realized include: increased efficiency, improved quality of care, and facilitation of patient evaluation and treatment coordination. Currently, there are billions of dollars in government incentives being offered to encourage the use of EMRs for quality reporting and data collection.
EMRs have also been touted by vendors as being able to provide greater accuracy in E/M coding with improved charge capture and increased reimbursement. But, there are risks involved when using EMRs for coding.
Although EMRs may contain coding templates or computer assisted coding (CAC) software, EMRs were not originally developed to be a coding tool. This conflict is the source of some of the problems associated with EMRs since some users rely solely on EMR code recommendations for their code selection.
As a result, there is increasing concern by the government, commercial payers, the health care industry, and outside critics, that EMR use increases opportunities to bill fraudulently. This concern has led Health and Human Services (HHS) Office of the Inspector General (OIG) to include a focus on evaluation and management (E/M) codes suggested or determined by the EMR software in the OIG Work Plans.
Following are a few tips to consider in order to use EMRs appropriately and effectively.
- Audit E/M code selection. Providers should be sure to compare the EMR’s E/M code recommendations to provider coded E/M visits to verify that EMR generated codes do not routinely represent different (higher or lower) levels of service.
- Review your notes to ensure that they are personalized, clinically accurate, clinically relevant, clinically useful, and complete. Sign notes only after they are reviewed.
- Invest time in customizing EHR templates to make them specific to your practice and to reflect your most common clinical encounters. Providers should also be aware of automatic macros and consider how, when and where they occur. (Macros allow users to fill in multiple fields using point and click capability).
- Beware of the possibilities for inaccurate Information when using the following EHR tools;
- Point and click
- Default entries
- Dropdown menus
- Review notes for incorrect or inconsistent information, such as:
- Discrepancies between HPI, ROS, and/or A/P
- Documentation and signatures
Cloning occurs when documentation is worded exactly like previous entries. Cloning of documentation does not meet the requirements for providing specific, individual information for each unique patient and as such, is considered a misrepresentation of the medical necessity requirement for service coverage. Identification of this type of documentation will lead to the denial of payment for services due to lack of medical necessity and may lead to recoupment of all perceived overpayments.
In summary, payers are willing to pay for services that are covered, medically necessary, and supported by documentation. However, effective use of EMRs for clinical documentation and coding requires human input and attention since the provider is ultimately responsible for all claims submitted.
Note: EMR and EHR (Electronic Health Record) terms are often used interchangeably.
As defined by the Office of the National Coordinator for Health Information Technology (ONC), EMRs are digital versions of a practice’s paper medical charts. EHRs also contain digital versions of the medical record but allow sharing of information beyond the original practice. With an EHR, information moves with the patient.
For more information on the risks and pitfalls associated with EMR documentation, see ACOG’s archived webcast: Coding Dilemmas When Using Electronic Medical Records.
ACOG's archived webinars may be accessed from the Education and Events page on ACOG website.