The four main areas for health practice administrators to pay extra attention to are cut and paste, grey areas, chronic problems and medical necessity. The following are tips for keeping these areas from becoming auditing problems:
— Avoid cutting and pasting history and examination on EHRs so they do not appear cloned, which could compromise record credibility.
— Be aware of how Medicare and commercial payors want grey areas documented.
— Some EHR systems are set up to list all of a patient’s chronic problems. Make sure only chronic problems relevant to the day’s encounter are submitted or else it would be considered upcoding or fraud.
— Know how your computer deciphers medical necessity so you can only submit visits supported by medical necessity.
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