Attorneys: Use strategies to reduce EHR documentation errors

Providers must take steps to reduce the risk of improper billing caused by their use of electronic health record functionalities that help with documentation, according to a recently published attorney advisory.

The advisory, from attorneys Adam Romney and Lisa Rediger Hayward at the law firm of Davis Wright Tremaine, points out that while EHR tools such as cut-and-paste or pull-forward functionalities are meant to help providers, they can render documentation and billing inaccurate when used inappropriately. However, since providers may not be able to rely on the actual medical record to demonstrate that the documentation is accurate, Romney and Hayward recommend that providers use other strategies to defend themselves.

These strategies include:

  • Establishing and following policies regarding proper EHR documentation to ensure accuracy and prevent inappropriate uses of the EHR tools
  • Using audit logs to reduce the possibility of billing fraud
  • Using EHRs safeguards, such as tracking documentation entry

"Providers should work with their EHR vendors to maximize the functionality of the software to accurately document patient records while incorporating appropriate safeguards into the program," they suggest.

The increased adoption of EHRs has led to increased concerns that the systems are being used to bill improperly for services provided to patients. The U.S. Department of Health & Human Services' Office of Inspector General is increasing its scrutiny of EHR billing this year. Several Medicare Administrative Contractors will no longer reimburse providers who use cloned notes.

To learn more:
- read the advisory

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