Pulmonology Coding Alert

Caution: Keep enough paperwork on hand to back up EHR. Transitioning to the world of Electronic Health Records (EHR) can make your coding easier on many levels, but don't take it for granted. Physicians often fall short in their review of systems (ROS) documentation, whether they use paper charts or rely on EHR, but you can help correct the deficiency. Consider this situation and decide how you would handle it before reading on for our experts' advice. Scenario: The pulmonology practice uses an EHR. One physician has a sheet listing any concerns or problems that the patient fills out prior to the visit. The pulmonologist uses the sheet for his (ROS) and for chart documentation. He lists anything the patient marks as positive and then states "see pt questionnaire." He then discards the form the patient completed. Concern: If the chart is audited, would the practice be required to produce [...]