Wiki EMR Compliance

[christydl]

The hospital I work at is currently transitioning to EMR. It has been said that we (billers and coders) will have limited access to the medical record due to HIPPA laws preventing us from PHI. I am in DIRE need to find documentation that states that I as the coder / biller need access to the patients chart in its entirity, just as I would the paper chart we are currently depleting. Any suggestions would be GREATLY appreciated.

 

[cheermom68]

You won't find documentation that all coders/billers need access to the entire chart. It has to be a case by case and facility to facility decision. HIPAA requires minimum access necessary to perform your job duties. There may actually be areas of the medical record that a coder may not need access too, for instance coders may or may not need access to psychotherapy notes. It really depends on what you are coding and what your scope of work is. It would depend on whether you are coding the facility charges or the professional charges or both. Your HIPAA/Compliance are should be meeting with your supervisor to determine what access that you need. You may need access to the entire record, but that will need to be determined and not just blanketly given to all coders/billers. If after your begin coding under this new system, simply talk to your supervisor about the issues you are having and your access can always be changed as necessary.
If there is a breech, the hospital has to show that it did its due diligence to adhere to the minimum necessary guideline.