Establish policy to handle patient medical record access scenarios, legally. Patients have a right to “request to view” their medical record. This right is conferred by the Standards for Privacy of Individually Identifiable Health Information, known as the HIPAA Privacy Rule of 2001 [45 C.F.R. § 164.524]. Let’s review legal details, so you can best ...
Mar 30th, 2017
Since electronic medical records (EMR) have become prevalent, there has been concern whether documentation in the patient record accurately reflects medical necessity and the services provided. When I started working in the healthcare setting, we always told providers, “Not documented, not done.” Now, when I review a chart note, the question I have to ask ...
A little preventive maintenance will ensure your physicians are capturing accurate documentation. Electronic health records (EHRs) can make documentation and billing processes easier, but some EHR features can leave your practice vulnerable in ways the vendor may not have explained. In the time it takes to drink a cup of coffee, you can perform some ...
In Audit
Sep 15th, 2015
by John Verhovshek, MA, CPC Electronic medical records have simplified documentation and record tracking. In some cases, the electronic record allows the physician to bring forward, or to “cut-and paste,” previous patient information. Although this may save time, progress notes are critical to support medical necessity. For example, if an inpatient’s improvement and/or regression is not ...
In Audit
Jun 30th, 2015
By Charla Prillaman, CPCO, CPC, CPC-I, CCC, CEMC, CPMA All pro-active medical practices perform coding/billing audits; some by practice staff and others by an outside vendor. These audits are usually designed to identify and, if necessary, remediate any gaps between medical record documentation and CPT, HCPCS II, and ICD-9 codes used for claims submission. Recent ...