Advanced Search

Gastroenterology Coding Alert

Templated EHRs Could Result in Incomplete Endo Notes

Published on Sat Jun 27, 2009

Physicians must take care that the record actually matches what they did. If you use a templated electronic medical record or a transcriptionist to save time, watch out, or you may end up losing the time you saved and then some when your coder has to come back to ask what really happened, or when a payer rejects a claim. "Make sure that you're reviewing the documentation from time to time that is transcribed," Jill M. Young, CPC-ED, CPC-IM, tells physicians. Don't expect coders to read your mind. "If you don't have a complete record, if the diagnosis isn't given or easily inferred (in the endoscopy note), you can't extrapolate that out." "If the provider's schedule starts to get rushed, they may be distracted and not pay close enough attention to the details that need to be changed in order to accurately report what they did," says Tina Smith, CPC, [...]
You’ve reached your limit of free articles. Already a subscriber? Log in.
Not a subscriber? Subscribe today to continue reading this article. Plus, you’ll get:
  • Simple explanations of current healthcare regulations and payer programs
  • Real-world reporting scenarios solved by our expert coders
  • Industry news, such as MAC and RAC activities, the OIG Work Plan, and CERT reports
  • Instant access to every article ever published in your eNewsletter
  • 6 annual AAPC-approved CEUs*
  • The latest updates for CPT®, ICD-10-CM, HCPCS Level II, NCCI edits, modifiers, compliance, technology, practice management, and more
*CEUs available with select eNewsletters.

Other Articles in this issue of

Gastroenterology Coding Alert

View All