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EMR and counting "bullets"

  1. #1
    Default EMR and counting "bullets"
    Medical Coding Books
    We have an EMR that I do not like. We follow the 1997 Documentation Guidelines. In a recent review of a doctor using the EMR the statement: Normal musculature. No skeletal tenderness or joint deformity." The EMR gave the doctor 7 exam bullets for that one statement. I know that there are 6 body areas in the M-S exam but how can all six areas be counted in such a general statement. Our EMR support people tell us that is correct. I want proof. This definitely can affect the doctor's coding and billing. Does anyone out there have any suggestions or remarks. I would not count this as 7. HELP!!!!! Lynn Kimsey, CPC-I

  2. #2
    I would count that as one Organ system- Musculo, I'm not sure how your EMR gets 7 bullets for that but I think I would request some type of explanation from your EMR support team to justify that.
    - Just a side note as an EMR trainer this is why alot of EMR systems get a bad reputation. I don't like when they count bullets, or assign codes. That should be left in the hands of the professionals.

  3. Default
    You are right to question this. We are going into an EMR and I am concerned about the same documentation problems. I too would count this as only one system. I would not rely on EMR support for coding clarification as they are not a credible source.

  4. #4
    Quote Originally Posted by nwinnen View Post
    I would not rely on EMR support for coding clarification as they are not a credible source.
    nwinnen, I just wanted to claify what I meant when I suggested she go to her EMR support for an explanation how the system get 7 bullets out of what I get one bullet on. I do realize that they are not there for coding clarification but as an EMR systems trainer I know that the programmers can look at the language used to write that portion of the program and give her the systems reasoning behind it. I would request that the programmers change the language to correct the problem or get something that states why the system can justify the upcoding.

  5. #5
    thanks for all your help and support. You know sometimes you over think things and it can drive you crazy. Unfortunately, our EMR support staff really do not completely understand what documentation is required and they listen to the EMR headquarters and not the coders or compliance. I will be revisiting this with our EMR people and request an explanation from the coders at the head office. They tell me they have them there. I do not want the doctors on EMR to get zinged for something that was programmed wrong. Thanks again for all yor help...Lynn Kimsey, CPC-I

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