Wiki EMR Info outside of note text

[TCLewis12]

There is some debate at the facility where I am a coder as to whether info that appears in our EMR software's print preview that is not in the note itself counts as part of a note's documentation. (Provider name, date of service, duration of visit, diagnosis, location, etc.) It has been argued that if it appears when printing a note from the software, it's acceptable, but that info outside of the note can be edited/changed by people other than the author of the note. For that reason, I have countered that all that info really should be contained in the text of the note itself, as only the author can edit or change it. What is acceptable in this case? - Thanks in advance . . .

 

[thomas7331]

I think it would depend on what you are coding, and whether you are coding for the professional providers or for the facility.

For the physicians and NPPs, you can only code what is actually documented by that provider. In some cases, as per guidelines, you may use outside notes if the provider has documented the location of the information and that he or she has reviewed those, but otherwise it isn't appropriate to give credit to a provider for work they haven't personally performed and documented, or to assign diagnosis codes that are not supported in their own documentation.

For facility coding, it's a little different since the facility is billing for the use of their resources. So facilities will charge for services performed by non-physician staff (e.g. blood draws, insertion of foley catheters, infusions, technical services, etc.) and those CPT/HCPCS codes may not necessarily be in the physician's documentation. But as far as diagnosis coding, with the exception of a few cases where ICD-10 allows that codes may be assigned based on documentation by clinicians other than the provider (e.g. BMI, pressure ulcer stages, coma scale, social information) the diagnosis codes assigned on the facility claim must be supported in the physician's actual notes.

 

[SharonCollachi]

So you're saying your provider name does not appear in the note and someone could change it? It's that's the case, that's a ginormous security issue that needs to be resolved.

 

[thomas7331]

Yes, agreed, that would be a security issue. However, all compliant EMRs have an audit trail that will show who authenticated any changes made to the record. The audit trail will not usually print out with the record, though, so you may not see it on the paper copy, but you should always be able to see in the system who actually authored or altered any entries to the record in the event that there is any question.