Auditing Issues Uncovered in Physician Documentation: Part III

By Terry Fletcher BS, CPC, CCC, CEMC, CCS, CCS-P, CMC, CMCSC, CMCS, ACS-CA, SCP-CA for ICD10 Monitor

Is your Electronic Medical Record (EMR) system helping you pass an audit or hurting you?

Editor’s Note: This is the third piece in a four-part series that examines physician documentation issues as seen by an auditor.

Click here to read part one: Auditing Issues Uncovered in Physician Documentation: Part I
Click here to read part two: Auditing Issues Uncovered in Physician Documentation: Part II

As we dive even further into the auditing pitfalls of a physician E&M audit, part two of our four-part series previously focused on the importance of a well-documented chief complaint and HPI (History of Present Illness), as this was a major pitfall in providers trying to pass an audit. The auditor relies on the presenting problem documentation to give the physician that medical necessity support to move forward with their documentation of a record.

As we move into part three of our series, this week, a major pitfall in an audited record comes from the Electronic Medical Record (EMR) itself and not necessarily the physician’s or provider’s documentation intent.

Article originally published on May 22, 2018 by ICD10 Monitor.