Subject(s)
Clinical Coding , Internal Medicine , Medicare , Clinical Coding/standards , United StatesABSTRACT
This article outlines the regulatory movement propelling physicians into the electronic health record environment and the subsequent emergence of quality issues in the medical record. There are benefits and downside risks for implementing electronic health records as part of the desire of a practice or institution to build patient-centered medical homes. The intersection of how a practice or institution collects and reports quality metrics using health information technology and subsequently submits claims for services rendered has created unforeseen challenges for which leadership must be aware and address proactively.
Subject(s)
Accountable Care Organizations , Documentation , Electronic Health Records , Insurance Claim Reporting , Practice Management, Medical , Current Procedural Terminology , Health Insurance Portability and Accountability Act , Humans , Quality Indicators, Health Care , United StatesABSTRACT
This article examines some of the potential problems inherent in the 1995 and 1997 Federal Documentation Guidelines and goes on to give some broad advice regarding documentation of evaluation and management (E/M) services. One small area covered by the guidelines, the history of present illness (HPI), is given some attention as an example of the variability of the guidelines. The use of templates and electronic medical records (EMR) is also addressed in terms of how auditors and regulators would like to see these tools used. A section is devoted to the most important elements of medical record documentation from an auditing perspective. A do's and don'ts section covers common areas of chart deficiencies and focus.
