Current Audit Challenges of an Electronic Health Record (EHR)

Compliance Officers of physician practices now have another concern when it comes to auditing compliance: their Electronic Health Record, or EHR. Documentation is one of many areas to consider when auditing physicians (billing/collection data, Current Procedural Terminology (CPT) utilization data).  While the implementation of the EHR has aided greatly in the documentation process, it also has brought on new compliance challenges. 

One example is the recent utilization of “Scribes.”  Scribes are assistants who accompany a physician into a patient visit and document directly into the EHR the respective diagnoses and treatments the physician relays out loud. This presents a compliance challenge as scribes typically enter in the information using the physician’s EHR log-in, unbeknownst to the compliance officer.
The copy and paste functionality of the EHR has also given compliance officers nightmares.  This function allows physicians to electronically copy the notes from a patient’s previous visit and paste it into the current visit.  If the notes are not edited to correctly reflect the specifics of the current visit, not only is it a non-billable service, it is now a compliance issue.

 There are ways to monitor a practice’s exposure.  A successful method to ensure compliance is for compliance officers to establish recurring documentation audits and provide continuing education to both providers and scribes.  Depending on the size of the practice, often times independent outside auditors are brought in to perform this task.  

Steven Bisciello is a Health Care Services Group Director experienced in revenue enhancement programs, health care litigation, compliance and physician practice management.

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