Protect your pediatric pay by avoiding these mistakes involving electronic health records. Many pediatric practices have found electronic health records (EHRs) to be a great way to save time and ensure that documentation is thorough and neat, but these helpful devices can also mislead you into creating documentation you don't need--and in some cases, can cause you to not document items required to support your code choices. Consider these three EHR myths, all of which are based on questions submitted to Myth 1: Exam Documentation Will Carry Over for Follow-Up Visits If your EHR is producing documentation that is robust in one section (such as History) and thin in another (such as Exam), you may be trusting the device to do too much. A subscriber recently told Reality: E/M guidelines state that if a patient's PMFSH has not changed since a prior visit, your provider doesn't have to document the information again. He does, however, need to document that he reviewed the previous information to be sure it's up to date and also note in the present encounter's documentation the date and location of the initial earlier acquisition of the PMFSH. Some payers will give no PMFSH credit if you overlook one of these criterion. For instance, you can say, "I reviewed the past, family, social history with the patient taken from today's patient questionnaire and our previous visit of June 1, 2012. She reports that nothing has changed since that date." However, there is no substitute for recording your physical exam information on each visit. For instance, suppose the patient presented with pain in the left ear in August and you documented a full exam on that day, prescribed medications, and told her to return if the pain returns. She comes back to your practice today because that left ear pain has flared up again, and you perform a full ear, nose, and throat examination. To get credit for a physical exam today, you will have to document the exam findings rather than trying to carry them over from the August visit. Even if you documented "left tympanic membrane is thickened and slightly erythematous" in August and that statement is still accurate today, you should document it again today. Myth 2: EHR's Calculation of Time Spent Qualifies You to Code Based on Time One of the perks of electronic health records is that they typically record the date and time that you input information. In fact, many EHRs record a summary of the time spent on the record at the bottom of each visit's documentation and give a total, such as "Total time: 26 minutes, 15 seconds." Several subscribers have told Reality: For example, the following statements would allow billing based on time alone: "25 minute office visit with 20 minutes spent on counseling about surgical and non-surgical options for recurrent otitis media" or "Total encounter: 55 minutes with more than 50 percent spent on coordination of care for patient's attention deficit disorder." In an EHR, you may not know where to put such a statement, but most of these systems will have a radio button somewhere in the software that you can press to create a comment box. As long as you enter your statement about time as indicated above anywhere in the record, you can code based on time, but simply stating the total time you spent--or letting the EHR calculate it for you--is not adequate. Myth 3: You Should Use the EHR's Code Selection in Every Case Your electronic health record will most likely offer an E/M code suggestion at the end of each visit--but that doesn't mean you can use that to justify all high-level codes. Several practices have told Reality: Therefore, you should use your EHR's code selection as a suggestion, but the final code choice should be up to the clinician, and should be based on medical necessity and the nature of the presenting problem. In addition, the history and physical examination provided should be commensurate with the presenting problem.