EMR Transition Is a Great Time to Refresh E/M Documentation Guidelines
By Brandi Tadlock, CPC, CPC-P, CPMA
If your provider is transitioning to an electronic medical record (EMR), take the opportunity to give him a “refresher” course on Evaluation & Management Documentation Guidelines. Many providers are actively involved with the purchase of their EMR systems, and undergo training on how to input information; however, that training often fails to account for the drastic change in documentation style that sometimes accompanies the new technology.
Some EMR features, such as Review of Systems and Exam prompts or MACROS, promise convenience and accurate E/M code selection. When properly used, these features can enhance the provider’s documentation by incorporating details that might have otherwise been overlooked. But for providers, all of the new prompted information can create confusion, leaving them second-guessing their understanding of how much documentation is really necessary to support the services they intend to bill. Consequently, they might overuse prompts, leading to notes that contain irrelevant, redundant, and/or conflicting information.
A simple review of the CMS guidelines can help your provider gauge the documentation he or she will need for each encounter. Emphasizing the importance of quality over quantity with regard to documentation requirements will make the transition to an EMR less overwhelming and allow your provider to make efficient use of the time spent recording each encounter, while facilitating truly accurate E/M code selection.