The transition to an electronic medical record can give providers the opportunity to refresh their knowledge of evaluation and management documentation guidelines, according to an AAPC report written by Brandi Tadlock, CPC, CPC-P, CPMA.
Ms. Tadlock said many providers are actively involved in the purchase of their EMR systems and undergo training on how to use the systems. However, the training sometimes ignores the drastic change in documentation style that comes with the new system. For example, some EMRs "enhance" provider documentation by incorporating details into E/M code selection that might have been overlooked in a traditional setting. But providers may be confused by the new prompts for information and may second-guess how much documentation is necessary to support the billed services. They may overuse prompts and enter redundant information because of this confusion.
Ms. Tadlock recommends providers review the CMS guidelines to determine how much documentation is necessary for each encounter. She emphasizes the importance of "quality" over "quantity" when documenting an encounter.
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Ms. Tadlock said many providers are actively involved in the purchase of their EMR systems and undergo training on how to use the systems. However, the training sometimes ignores the drastic change in documentation style that comes with the new system. For example, some EMRs "enhance" provider documentation by incorporating details into E/M code selection that might have been overlooked in a traditional setting. But providers may be confused by the new prompts for information and may second-guess how much documentation is necessary to support the billed services. They may overuse prompts and enter redundant information because of this confusion.
Ms. Tadlock recommends providers review the CMS guidelines to determine how much documentation is necessary for each encounter. She emphasizes the importance of "quality" over "quantity" when documenting an encounter.
Related Articles on Coding, Billing and Collections:
AMA Opposes ICD-10 -- Now What?
What Does Dr. Don Berwick's Departure Mean for ICD-10 Implementation?
Medicare to Pay for Obesity for Screening and Counseling