Electronic Health Records (EHRs), when used correctly, produce more accurate documentation leading to more complete coding, and ultimately, more accurate reimbursement claims, according to Sue Bowman, senior director of coding policy and compliance of the American Health Information Management Association (AHIMA), during her presentation on May 3 at a listening session hosted by Centers for Medicare & Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for Health Information Technology at the Department of Health and Human Services (HHS).
The session, “Billing and Coding with Electronic Health Records,” convened stakeholders including providers, health association leaders, health information technology vendors and others to discuss EHRs, increased billing for some services, and appropriate coding in an increasingly electronic environment.
During her presentation on developing EHR coding standards, Bowman called for more research on the causes of higher levels of coding and reimbursement, according to a press release released by AHIMA.
“The extent to which EHRs have led to improper reimbursement is unclear,” Bowman said. “EHRs produce more complete and accurate documentation, and this could be leading medical providers to seek reimbursement for services they have always been providing, but weren’t properly documenting before. Higher levels of reimbursement do not necessarily equate to fraud.”
EHRs offer many benefits, including saving time, prompting clinicians for documentation, and improving consistency and completeness in medical records, said Bowman. On the other hand, they also have some features that can be risky if improperly used, like copy/paste, auto-creation of default documentation, and templates with limited options.
“If EHR systems are not properly designed and used, they can lead to inaccurate, outdated or misleading information,” said Bowman. “That’s why all EHR users should receive comprehensive training and education on how to use them correctly. Real improvements in documentation and coding should be rewarded, and misuse should be punished.”
To address the problems concerns about EHRs, AHIMA made several recommendations, including:
- A code of ethics for both EHR vendors and users to design and use the systems correctly, and shared accountability for ensuring compliant documentation and coding practices
- Organization guidelines to assure the features of an EHR are used correctly, addressing issues such as acceptable ways to capture information, limitations on certain features and correct copy/paste practices
- A national set of coding guidelines by CMS for hospital reporting of emergency department and clinic visits
- Education and training on EHR use for all who access it
