South Florida Hospital News
Monday August 10, 2020

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September 2013 - Volume 10 - Issue 3


Electronic Medical Records: Are They a Blessing or a Curse?

The widespread use and availability of electronic medical records have brought about more changes and opportunities than we have seen in centuries. Unfortunately, the challenges that accompany the use of EMR are equally notable. With the government designating billions of dollars in incentives for adopters of EMR, the pitfalls of the use of EMR are becoming more and more apparent. Initially, and still today, EMR is viewed as a means to expedite claims submission and reimbursements, reduce inconsistent procedure codes, and detect human errors in the data entry process before claims are finalized and submitted. Thus, providers have long thought that use of EMR would add dollars to their bottom line. In reality, providers are learning the hard way that the lure of ease and speed comes with a price tag – extra time outside of routine office hours needed to think creatively to differentiate, detail and substantiate care provided to the patient so that third party payors do not deny or down code claims.
While the design of EMR is focused on automating and streamlining claims processing, there is a technical side of the coding that goes beyond mere code selection. Using copied or pre-populated data generated from prior patient visits to speed data entry increases the chances of having conflicting and inaccurate data in a patient record, leads to non-compliant evaluation and management claims, and may result in up-coding, all of which bring greater scrutiny from third party payors and increase the number of claims denials.
As third party payors scrutinize claims submission data more closely, providers have to take precautions by using scrubbers and spending a significant amount of time in customizing visit templates and recognizing that EMRs have short comings. EMR is a wonderful technology, but it is not a substitute for claims editing. EMR does not obviate the need for a provider to create an accurate patient record that is unique to each patient, different from one visit to the next, and clearly documents medical necessity. When entering notes, a provider should consider what the record would look like if he or she were handwriting the note. In addition, just because an EMR will calculate services to yield a higher level of care, it does not mean a provider can actually bill the services at the higher valued evaluation and management code. Providers cannot simply accept that the algorithms in an EMR are correct.
No matter how integrated and sophisticated the EMR, the government and other third party payors are always 10 steps ahead with their technology and claims data analysis. Payors are aggressive in their review processes and know the shortcomings of EMR. They use this knowledge to their advantage. To reduce vulnerability to government and payor audits, providers need to constantly remind themselves that documentation in an EMR should not be about coding. Documentation should be about patient care and providing enough details for another provider reading a record to be able to clearly understand the patient’s history, exam, condition, the treating provider’s cognitive process, the extent of counseling and any coordination of care. This approach will not only thwart payor audits, but it will protect a provider from any liability associated with lack of documentation in a malpractice suit.
Is this easier said than done? Without question. Scribes can make the process a little easier, but there is no substitute for taking extra time to “un-can” EMR chart notes and making sure there are systems in place to review and correct data entered into a record. With the government focused on recouping money, spending money on a scribe, may be money well-spent.
Heather Miller is senior counsel in the Boca Raton and Miami offices of the statewide law firm, Broad and Cassel. She may be reached at or (561) 218-8861.
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