Wiki EHR verifications by coders

[OBcoder2017]

I have not worked with EHR yet, but understood that once the docs submit the record, nothing can be changed. However, I am reading in the forum about the importance of coders verifying accuracy of electronic health record documentation prior to claim submission. Is this happening? Can someone speak to this and explain when the coders intervene between EHR input from the docs and the actual claims submission.

Also, after the doctors are clicking on the diagnoses with the embedded codes, do they then also type in their own notes to document into the EHR? I have no idea the steps that the EHR takes before it gets submitted for claims and would be interested in hearing from those of you that are working with them. Thanks.

 

[maycricket]

I have some limited experience with EHRs as I do not work in them much, but occasionally audit E&M records. I believe (depending on the system) there is a way to amend a record if necessary. In our system, the billing will not take place when there is a crosswalk error or an LCD/NCD issue. That is when the AR Manager flags me to review the documentation. Our providers may choose to type in their own notes or not, and we can set up templates that are specific to whatever specialty we need. We are actually looking at doing that right now for one of our General Surgeons for his office visits that result in EGDs. One issue is making sure the provider does not get into a "habit" of just clicking all the same information for the same OV before a certain procedure; each visit must be specific to that patient.