Health Information Management

PPV: Watch out for EMR-related coding pitfalls

HIM-HIPAA Insider, March 13, 2007

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There's a new trend in coding--and it's a dangerous one. Physicians are using electronic medical record (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.

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