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Tip of the week: Turn off the coding function in your EHR

EHR Connection, April 23, 2007

There's a new trend in coding--and it's a dangerous one. Physicians are using EMR software with built-in coding intelligence to choose CPT evaluation and management (E/M) coding levels. The risk in using the EMR to code visits is high, says Deborah Grider, CPC, CPC-H, CPC-P, CCS-P, CCP, EMS, president-elect of the Salt Lake City-based American Academy of Professional Coders National Advisory Board. "If you turn the coding function on, it will actually prompt a physician to upcode." For example, the EMR will prompt a physician with a message such as, "If you complete one additional review of systems, you can bill a level four." This is a real problem, says Grider.

Grider suggests that practices turn the coding functionality off. She explains that vendors are just now learning that their templates aren't clinically appropriate, so they're back at square one, hiring physicians as medical directors to improve product quality. But until EMRs become so sophisticated that they're right on target, a physician can't rely on one to code. It's safer to manually assign codes.

Don't rely on an EMR to make the final decision on the correct code level. It's okay to use tools, says Grider. "But I believe wholeheartedly that a person needs to make the final decision."

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