Meet Your Coding Needs With the Right EHR

by Patricia S. Wilson, RT (R), CPC, PMP

An integral part of the coding process is to verify that documentation supports procedures and services performed. Although documentation of medical services and procedures seems a logical part of medical practice, it sometimes is a secondary function of medical care. The concept of medical documentation as a secondary function in medical care is not a new concern, as Florence Nightingale referred to it in 1863:

“In attempting to arrive at the truth, I have applied everywhere for information, but in scarcely an instance have I been able to obtain hospital records fit for any purposes of comparison. If they could be obtained … they would show subscribers how their money was being spent, what amount of good was really being done with it, or whether the money was not doing mischief rather than good…”

Service documentation is sometimes considered by clinicians as an onerous obligation of their profession. They rarely see the immediate benefit of clearly and completely dictating or writing down what they did. Many see it as a means to keep the HIM, coding, and compliance departments out of their hair.

As Florence Nightingale indicated, it is the lack of precise, clear, and complete medical documentation that often causes mischief—not only for the provider, but for the patient, too.

In 1999, the Institute of Medicine (IOM) published a study indicating 98,000 patients die every year primarily due to inadequate medical record charting and reporting. The use of an electronic health record (EHR) was sited as being a key mechanism to support quality and efficiency in patient care. The health care industry took this information to heart. Over the following years, a variety of EHRs came on the market to solve the problem of incomplete, low quality medical documentation. The federal and state payers are changing the reimbursement paradigm from frequency based to quality based.

There are as many different types of computerized or electronic health record types as there are acronyms used to describe them. The health care industry has struggled to define what is necessary to make health care information consistently of good quality and used by the provider. Less than 10 percent of small physician practices use a form of an EHR and with large practices about 30 percent use one. The adoption of EHRs by hospitals across the country is somewhere in the range of 16 percent to 56 percent. The reason for the huge variance in hospital EHR adoption statistics is due to the variable definition of an EHR.

The professional coder can lend a voice in the area of EHR definition and adoption. There is a significant shift in health care reimbursement with the desire to provide high-quality health care. The EHR is the silver bullet to assure good documentation and provide quality health care. However, the silver bullet may shoot right through the coding process and—more importantly—compliance if the coder and compliance officer are not included in the process up front.

The medical coder and compliance officer are sometimes overlooked as important stakeholders when a medical practice or hospital is purchasing an EHR. Instead of waiting for an invitation to the decision making process, the coder and compliance officer, in most cases, need to outline their points of concern. Here are some ‘gotcha’ points  for the coder to consider when purchasing or implementing an EHR.

The overarching question to ask is how will the EHR operate with the existing billing system? The answer to this single question determines additional questions asked and to what extent the EHR could change your current coding practices.

Here are secondary questions to ask that determine how the EHR will impact coding:

Is it a stand-alone EHR? This means that it does not interface with any other electronic medical system, especially the billing system. A stand-alone system requires double entry of outside information into the EHR. It is highly unlikely that even a solo medical practice would never refer a patient to a hospital, imaging center, laboratory, nursing home or other medical service. Double entry data leaves room for human error and inconsistencies, takes extra time and effort, and is a red flag for a compliance officer.

To what extent does the EHR “auto-code?” EHRs have a mechanism for suggesting both diagnostic and procedural coding based on the clinician’s data input. The system could be a template-based format that prompts the clinician to fill in information they may otherwise have missed. Other systems use natural language processing to parse out certain words and phrases to determine the diagnosis and procedure. The issue with EHRs that auto-code is the extent to which they can adhere to specific coding rules established by local and even federal insurance carriers. Even the best auto-coding system requires some measure of review and a method to override the suggested codes. This leads us to the next question to ask:

If the EHR does auto-coding and is able to interface with data flowing into your existing billing system, can data flow back out of your billing system and into the EHR?

This is an essential component for auditing and compliance. If a suggested EHR diagnosis or procedure code should be over-ridden for claim submission, the change should be input into the EHR for the purpose of audit tracking. Many EHR systems are recognizing this need and upgrading their systems to provide a complete coding audit trail.

There are several other questions to consider depending on your practice. The most important is how flexible is the candidate system at implementing coding and billing changes required by the industry. Medical practices rely on coders and compliance officers to provide accurate, complete, and consistent coding for their financial benefit. It is up to you to take an active role in staying abreast of how an EHR will impact your workflow and the bottom line.

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