Electronic Medical Records Require Changes to Coding Processes

Electronic medical records or EMRs, will require changes to the way in which medical coding is accomplished.    To start, electronic medical records and electronic health records, although similar, are not the same. The terms have been used interchangeably in the marketplace but there are differences.

The EMR is a record of a patient’s medical status and interaction with professionals in the practice which is used for diagnosis and treatment protocol recommendations as well as to determine medical coding.  The EHR is a more robust usage of the EMR and can follow the patient from practice to practice as an electronic record.  Both include diagnostic testing, records, results, imaging, insurance information and medical information but the EHR can also allow physicians to message each other and allow for data exchange between offices.

Physicians Beware of EMR Software Purchasing Assistance  If a clinical laboratory offers your physician’s practice financial assistance to acquire electronic medical record (EMR) software, listen to the sirens going off in your head and run the other way. There’s probably a catch, and it’s probably illegal.

Although the EMR is a wonderful way of improving record keeping and streamlining medical record and billing, there are also problems that come with the process.  Be sure before recommending software to the practice that you check the legalities of the software.

In some instances laboratories are offering to pay practitioners up to 85% of the cost of the EMR software in exchange for which the practitioner office will exclusively use the services of the lab. Although, it may appear to be legal on the surface, this type of exchange may be in violation of the Federal Anti-Kickback Statute. This can result in penalties, so the office should consult their attorney before undertaking any contract agreement.

Increase reimbursements with electronic coding, billing:  The last several years, orthopaedic practices have seen professional reimbursements decline while practice expenses increase. According to AAOS census data, . . .

Using electronic medical records will improve the coding process by allowing the physician to enter medical information during the office visit that is simultaneously coded by the system and checked by the practitioner.  This relatively seamless process improves the reliability of the programming and increases the probability that the practice will receive the correct reimbursement for the visit.

This also reduces the chances for fraud and the necessity for re-billing insurance companies when the coding is not accurate.  There are several different pieces of software available.  The medical billing and coding specialist for the office should be involved in the decision process to ensure that the software chosen meets the individual needs of the practitioners in the office, the insurance companies with which the office interfaces and that it can be seamlessly integrated with the coding software used by the practice.

Unfortunately,  EMRs can also be problematic because physicians can create templates for their office visits, making it all to easy to click a button, install the template to the patient medical record and not make any changes that are pertinent to this particular patient file.  This increases the risk that during future visits the physician or practitioner will be unable to recreate the past medical record accurately, negatively impacting the way in which a patient is treated.

These negative consequences have a significant impact on care but will not change the billing procedure.  Certified medical billing specialists can continue to monitor the medical records and note these changes so the practitioners can be made aware.  Insurance companies can interpret these duplicate records as fraud and medical specialists can help to reduce this potential.


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