Electronic Health Records (EHR) and Electronic Medical Records (EMR) often come with software to “advise” you about coding. This advisory software is promoted as increasing your revenue by advising you that if you document more, you can increase your CPT to a higher level. If you document completely, your level 3 visit can become a 4, or even a 5.

In reality, the services provided must be appropriate for the diagnosis given. Level 4 and 5 billings will readily be identified and should be expected to be challenged. Don’t assume that your automated code advisor with your electronic medical records software will have eliminated these challenges. If the diagnosis does not fit, the CPT code is declared excessive.

Somewhere in the documentation of your software is a disclaimer that explains that their code advisor is simple advising, the determination of the appropriateness of coding, and the responsibility-liability-for the actual coding remains the physicians’ responsibility. Watch the diagnosis as well.

The level of services provided must also be commensurate with the diagnosis under treatment. While all the requirements of a level of care may be fully and completed documented, does the diagnosis under treatment warrant the level of service? Increasingly payers are using computerized models to compare CPT codes with the diagnosis codes and identify patterns of what they allege to be excessive services for the diagnosis listed. For Example, an ear infection in an otherwise healthy patient would be difficult to justify level 5 E/M, even if the level 5 were fully documented according to the documentation standards.

At Medcare MSO Electronic Health Records Company we make sure that codes are compliant with the level of care and AMI regulations. To become a client or schedule a demonstration, please reach us at 800-640-6409.

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