Reap Benefits of EMR But Don’t Let it Dictate What to Document & Which Code to Use

Thu, Jun 26, 2014

HIT Help Desk

The E/M code suggestions offered by your EMR can be helpful; but that does not mean you can use that to justify all high-level codes.

Using electronic medical records (EMRs) in your practice comes with umpteen benefits – Be it saving time, creating legible documentation or sharing history with fellow providers. However, relying too heavily on EMRs could come with its own pitfalls.

Heed these three tips to know where your EMR system could be leading you astray:

Exam Documentation Does Not Carry Over

You may be relying on your EMR too much if it constantly shows E/M documentation that’s robust in one section and not so in another (such as exam). To cite an example, an auditor down-coded many of a practice’s E/M claims due to empty ‘physical exam’ sections in the documentation. The practice explained that the EMR vendor had told them that patients being seen for established problems…

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