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How EHRs Can Cause Inaccurate E/M Coding

Many EHRs come with automated evaluation and management (E/M) coding tools, the suggest a level of service to a provider either during or at the end of an encounter. Many of the systems that have been reviewed by the author have not met a standard that allows them to be used reliably….

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Cutting Costly Codes Act of 2013 and ICD-10-CM

Below is the text taken from a government website.  Even though it was drafted in 2013 and is representative of efforts in Texas to seek a delay in ICD-10.  The text of the bill is provided here.  More current information on this topic is available from AHIMA at the following location. 113th CONGRESS 1st…

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Prepare to Fight ICD-10-CM Denials

ICD-10-CM will be the mandatory code set for reporting starting on October 1, 2015, unless another unforeseen issue arises in the federal government that leads to its delay.   The complexity of ICD-10-CM as compared to ICD-9-CM have gone up markedly.  This will increase the likelihood of inaccurate coding at the healthcare provider institution level, coding…

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Beware of the Problem List in Compliance Audits

The problem list is a required feature of certified EHRs and must be used by providers in order to attest for Meaningful Use, starting with Stage 1.  Prior to Meaningful Use, problem lists were used inconsistently in the outpatient setting.  They have greatest value in primary care and are intended to…

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CMS Allows Combination of 95 and 97 E/M Guidelines

For 16 years CMS did not allow the 1995 and 1997 versions of their Documentation Guidelines for Evaluation and Management Services to be used interchangeably.  However, in September of 2013 CMS decided to modify this rule in a little known decision that is detailed in this article.  CMS now allows for history of present…

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Opportunity Opens for Coders in the Digital World

Coding professionals should take advantage of advances in health information technology and the now ubiquitous electronic health records (EHRs).  The demand for HIT professionals with terminology knowledge has never been greater.   The days of ICD-9-CM will soon be behind us, and ICD-10-CM and SNOMED CT will become the dominant…

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Doctor Admits to Copy and Paste in EHR Records and May Face Accusations of Fraud

A Veterans Health Administration pulmonologist admitted to the copy-and-paste of prior information entered by other providers into the assessment of over 1200 patients.   Prosecutors are saying this may amount to falsification of a government document. The article is available here. This would appear to be a grey zone unless the…