EHR Medical Coding – Know the Challenges Involved

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EHR Medical Coding - Know the Challenges Involved

• Electronic Health Records (EHRs) ensure more
  accurate documentation, more complete coding,
  and ultimately, more accurate reimbursement
  claims.
• With information readily available on HER-
  integrated billing software, medical coders can
  review and start the coding process as soon as
  the patient is discharged.

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Proven Benefits and Risks

• Practices using EHR software find their billing
  processes streamlined because procedure and
  diagnosis codes are automatically created
  and assigned.
• Services of skilled medical coders could be
  crucial to review these codes and ensure
  that compliance with CMS and private payer
  guidelines.
• Reported benefits include
• Time-saving
• Better documentation
• Improved consistency and completeness in
  medical records

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Proven Benefits and Risks

• Certain risks involving improper use of EHRs
  are
• Copy/paste
• Auto-creation of default documentation, and
• Templates with limited options.

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Copy and Paste Issues

• Excessive copying and pasting of notes in EHRs
  result in inaccurate, outdated, or incomplete
  information.
• Copy- pasted notes bring issues such as
• Compromising communication among the
  members of the care team
• Medical errors resulting from inaccurate or
  outdated clinical information, and
• Chances of missing important pieces of
  information

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AHIMA Standards on Copy and Paste Functionality
Use

• Develop policies/procedures addressing the
  proper use of the copy/paste feature to ensure
  compliance with governmental, regulatory, and
  industry standards
• Address the use of features such as copy/paste
  in information governance processes
• Provide comprehensive training and education on
  the proper use of copy/paste to all EHR
  system users
• Monitor compliance and enforce
  policies/procedures regarding use of copy/paste
  and institute corrective action as necessary

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Avoid EHR Shortcuts

• Never use EHR shortcuts, as it can lead to risks
  for physicians.
• By using shortcuts, untrained staff members may
  miss revenue opportunities for the practice
  and create a backlog of carrier denials.
• To avoid coding errors, healthcare providers
  should
• Employ well-trained staff responsible for the
  medical coding process
• Ensure proper training for all medical staff
  involved in the medical coding process
• Invest in medical coding certification training
  for all coding staff

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Professional medical coding companies offer the
services of certified medical coding specialists
to protect both patients and providers against
delayed, denied and incorrect reimbursement.
CONTACT
Headquarters8596 E. 101st Street, Suite
HTulsa, OK 74133Main [phone]Fax
[phone]E-mail info_at_managedoutsource.comU
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