When electronic medical records (EMR) were first introduced, some observers predicted that electronic documentation would mean that medical coding inaccuracies would soon be a thing of the past. Indeed, today’s EMR systems include algorithms that can automatically make front-end edits and catch documentation mistakes, thereby preventing certain miscommunications between physicians and coders — which would otherwise cause coding errors that lead to problems with reimbursement. However, EMRs have introduced problems of their own, so inaccurate medical coding is still a very real risk. Read on to learn more about the challenges of interpreting EMRs for medical coding purposes.
Documentation Challenges Associated with EMRs
Today, most health care practices in the United States are using EMRs, but even some of the most popular EMRs on the market present challenges for physicians who are using them to document patient visits. For instance, a review article published in the Journal of Healthcare Communications in 2016 revealed high levels of dissatisfaction with EPIC — one of the most popular EMRs on the market — for the documentation of certain procedures. In particular, a full 50 percent of primary care physicians reported low satisfaction with the system’s options for the documentation of cancer screenings. About 25 percent of physicians even reported struggling with the documentation of procedures as simple as vaccinations.
Another aspect of EMRs that can lead to miscommunications between physicians and medical coders is the use of templates for medical progress notes. These templates are designed to streamline the documentation process, but they also make it easy for a physician to accidentally click the incorrect box and indicate that a man is pregnant or that he received a PAP smear. When medical coders do not notice these mistakes and submit error-ridden forms to insurance payers, it can lead to problems with reimbursement — including both overpayments and underpayments. The payer may also flag the practice for increased scrutiny in the future, which can ultimately slow down your revenue cycle.
Outsourcing as a Solution to EMR-Related Problems
If you are concerned about the medical coding problems that can arise from the use of an EMR system, you may want to consider outsourcing your medical coding. The experts at AnnexMed are trained to interpret documentation from physicians who are struggling with tricky technology or dealing with confusing templates. We can catch errors that would otherwise cause problems with reimbursement, ensuring that your practice can make the most of EMRs without having to deal with the associated coding problems. Contact us today for more information about our services!
- Posted by admin
- On January 9, 2018
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