Wiki EMR vs Hard Copy Notes Audit

[linc11]

Hi Everybody

Does anyone know if auditors review the hard copy finalized report the physician generates from the EMR or will they also review the patients records in the EMR itself including the templates that the information is generated from?

Reason I ask....I'm noticing that all though services are documented within the EMR templates not all of the information is populating on the finalized report for the visit.

Thank you!

 

[martinni1974]

Hi Lisa,

It will depend on the type of audit being conducted. Sometimes the payer will request copies of the doucmenation to be mailed to them, and sometimes they will come on site and review the documentation right out of your EMR. Your contracted payers are permitted to come onsite to review documenation.

If documentation is not populating you should reach out to your EMR tech support and have them resolve it as soon as possible. If the printed documentation is missing, key elements to support your coding whether EMR generated or manually, this issue still leaves your practice open to being downcoded, extrapolated, and penalized for the instances where something is printed, missing important info, and sent in to the payer.

Good Luck!

 

[linc11]

Thank you Nicole!

I've been working diligently wth our EMR team getting this issue resolved and sometimes I'm finding it's user error as well and additional education using the EMR templates is necessary. I've pointed out that most times when an audit letter is received and a response is sent by our billing office, it's in the form of the Master Document which in some cases does not reflect the whole picture of the services rendered to the patient. Scary I know. Someone suggested sending copies of the filled out templates but I'm not certain that is an option. Thanks again for your answer!