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Oncology & Hematology Coding Alert

Labs:

36415 Documentation Should Specify Method to Ease Audit Worries

Published on Tue Apr 12, 2011

Follow this advice to be sure your EHR isn't setting you up for trouble.Electronic health record (EHR) documentation templates can be a blessing and a curse.Case in point: If your system doesn't prompt clinicians to document the method of a blood-draw, auditors may decide documentation fails to support your code choice for the procedure. Steer clear of this trap with expert insights into the documentation you need and how you can be sure you get it.See How Method Matters for Code ChoiceBefore EHRs (also called EMRs or electronic medical records) took hold, labs typically had a collection log where they would document how and at what site a specimen was drawn. Now, an EHR may provide the information for a venous blood draw. It may neglect, however, to tell you what method was used for the draw.For example, the EHR may show: "Specimen: blood, Drawn: at 1pm, By: Suzie Q [...]
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