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www.outsourcestrategies.com
 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.
EHR Medical Coding - Know
the Challenges Involved
www.outsourcestrategies.com
 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
Proven Benefits and Risks
www.outsourcestrategies.com
 Certain risks involving improper use of EHRs are:
 Copy/paste
 Auto-creation of default documentation, and
 Templates with limited options.
Proven Benefits and Risks
www.outsourcestrategies.com
 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result in inaccurate, outdated, or incomplete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outdated clinical information, and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
Copy and Paste Issues
www.outsourcestrategies.com
 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
AHIMA Standards on
“Copy and Paste”
Functionality Use
www.outsourcestrategies.com
 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
Avoid EHR Shortcuts
www.outsourcestrategies.com
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
Headquarters:
8596 E. 101st Street, Suite H
Tulsa, OK 74133
Main: (800) 670 2809
Fax: (877) 835-5442
E-mail: info@managedoutsource.com
URL: http://www.outsourcestrategies.com
Thank You…

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EHR Medical Coding – Know the Challenges Involved

  • 2.  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. EHR Medical Coding - Know the Challenges Involved www.outsourcestrategies.com
  • 3.  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 Proven Benefits and Risks www.outsourcestrategies.com
  • 4.  Certain risks involving improper use of EHRs are:  Copy/paste  Auto-creation of default documentation, and  Templates with limited options. Proven Benefits and Risks www.outsourcestrategies.com
  • 5.  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 Copy and Paste Issues www.outsourcestrategies.com
  • 6.  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 AHIMA Standards on “Copy and Paste” Functionality Use www.outsourcestrategies.com
  • 7.  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 Avoid EHR Shortcuts www.outsourcestrategies.com
  • 8. 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 Headquarters: 8596 E. 101st Street, Suite H Tulsa, OK 74133 Main: (800) 670 2809 Fax: (877) 835-5442 E-mail: info@managedoutsource.com URL: http://www.outsourcestrategies.com Thank You…