Are You Avoiding EHR Perils?

Electronic Health Record (EHR) systems are an integral part of today’s healthcare.  Not only do they provide quicker, easier, and more accessible means for storing patient health information, most EHRs offer critical features that help providers to properly document and report meaningful use.  Per Clements (2017), EHRs can be beneficial in a variety of ways, such as:

  • Allowing for more efficient, complete, and legible documentation
  • Providing easier and immediate access to medical records and patient information
  • Coordinating care among providers

EHRs are designed to assist and help providers by offering a more technologically advanced means for storing and accessing patient health information. Even with the numerous benefits that EHRs provide, they are not without potential pitfalls and limitations.  Clements (2017) points out areas in which EHR features may be used inappropriately or inadequately:

  • Many EHRs offer a “cloning” or copy and paste feature, which allows physicians to transfer information from prior visits that may be relevant for a current visit in a fast and efficient way.  However, auto-populating or copy and paste/cloning features can potentially lead to fraudulent or inaccurate documentation.  Documentation may be carried over that is no longer relevant to the patient or is not relevant to the current visit.
  • Building off the cloning point, over-documentation can also be a problem.  Copying and pasting, auto-population, or simply over-documentation to justify the billing of a higher evaluation and management (E/M) code is fraudulent and unethical.  Each visit should be documented based on what occurred during that particular visit.  It is best to not use the auto-population templates or cloning features to avoid these issues entirely.   I cannot stress enough that over-documentation does not equate medical necessity for billing higher-level E/M codes. E/M codes should meet all of the specified CMS guidelines for medical necessity.
  • Some EHRs offer the provider the ability to generate diagnosis and procedure codes based on descriptors in the documentation.  While this is clearly an efficient means for documenting patient conditions and procedures performed during a given visit, it is NOT to be solely relied upon.  Providers or other clinical employees should ensure that all diagnoses and procedures are coded and generated appropriately.  With the onset of ICD-10, diagnosis codes should be monitored for the highest accuracy and specificity possible and unspecified codes, which from my experience are the most commonly auto-generated in EHRs, should be avoided.

More and more often in the medical billing industry we are seeing insurance companies control for appropriate and accurate billing (e.g. medical records requests, CMS initiatives) through companies such as Optum.  Insurance companies are only ensuring that providers are maintaining authentic patient medical information and are billing only what is accurate and necessary. Poor or inappropriate documentation due to the above mentioned EHR issues can lead to insurance denials and fraudulent billing, both of which providers and medical billers certainly want to avoid.  At MedPro Services, we strive to find EHRs that fit our providers’ needs and consult on ways in which the EHR can be used more effectively and appropriately where applicable.  We are familiar with numerous EHRs and are always willing to provide recommendations.  Please contact us for more information.

Clements, A. (2017, October). Conquer E/M challenges of EHRs. Healthcare Business Monthly, 46-49.


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