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Documentation and Coding Challenges with EHR – Administrative Eyecare

The American Recovery and Reinvestment Act (ARRA) of 2009 authorized the Center for Medicare and Medicaid Services (CMS) to provide financial incentives for physicians who are “meaningful users” of certified electronic health record (EHR) technology and impose penalties for those who do not adopt EHR by 2015. This incentive and the potential penalties forced many physicians to make the leap from paper medical records to EHR. Implementation of EHR presents a myriad of challenges including system selection, workflow process changes, security of protected health information (PHI), and obtaining staff and physician commitment to EHR compliance. One aspect of adoption requiring significant attention is the challenge of accurate, meaningful documentation and correct coding.

This article addresses the following topics:

  • Pre-populated charts
  • Copy-forwarding patient information
  • Nonsensical notes
  • Correctly identifying addenda, corrections, and amendments
  • Proper code selection

This article was published in Administrative Eyecare, and was written by Corcoran’s Vice-President, Donna McCune, CCS-P, COE, CPMA. To access this article, click on the link below:

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