Wiki Coding OV when EMR template used

Create Wiki
T

tlewiscpc

Contributor
Messages
18
Location
Gold Hill, NC
Best answers
0
How do other handle coding when physicians use EMR which is templated to pull into each note the PMSH?

I have a physician who has ov note templates and this info is pulled into each note. I have no idea if he reviews it or not. My thought is that it shouldn't be counted as an element in coding the level but I'm interested in how others handle this.

Thanks in advance.
 
Be very careful when you are arbitrarily deciding not to count things that are documented. Yes, EMR's can make it easy (too easy sometimes) to pull the information into the chart, but the provider does normally need to check it off to pull it into the note, and they should be reviewing it to make sure it is up to date.

Now, if that info bumps the history to comprehensive, and the exam is also comprehensive, I'm not saying that they are all 99215's. They should be coding in line with the medical necessity.
 
Agree with Mike.

Another way to look at it is that even if it's brought automatically into the note, the provider is still e-signing for everything in that note. It is not up to us to determine what the provider did or did not read.

Otherwise, we may as well go back to paper charts
 
Good points. What if the template pulls that info in automatically - he isn't checking anything that makes it pull into the note?
I see our PMSH is always the same on all of our patients. It never seems to change. Our template is constructed in such a fashion that those sections are pulled into the note automatically without having to select or click anything to make it do so., just like lab results, so I wasn't sure. It makes me uncomfortable to give credit for that when I know that technically it's not being reviewed but I agree with the points made.
 
tlewiscpc said:
Good points. What if the template pulls that info in automatically - he isn't checking anything that makes it pull into the note?
I see our PMSH is always the same on all of our patients. It never seems to change. Our template is constructed in such a fashion that those sections are pulled into the note automatically without having to select or click anything to make it do so., just like lab results, so I wasn't sure. It makes me uncomfortable to give credit for that when I know that technically it's not being reviewed but I agree with the points made.
Click to expand...

That is a concern I have as well. I have seen numerous occasions where the documentation on PFSH or ROS that is pulled in from previous visits conflict with other parts of the record. Common example I see: patient updates her face sheet information, and marital status has changed (and therefore insurance, etc) but on that day's progress note, the old marital status is documented in the social history. Now one of these is incorrect - guess which one I would tend to say is correct?
 
TLewis,

if you have a CAC (or whomever does your EHR maintenance), see if he/she can fix it so the provider must click on boxes and/or type into text boxes to update vs. having it autofilter into the visit
 
The provider has to document what he/she reviewed and when and also what the date was of the original PFSH they are reviewing. If it conflicts with the rest of the note, than it's an educational opportunity and I would personally never count it. We all have a love/hate relationship with EMR and I pray it gets better. Providers should be paid for their work and their obligation to go to EMR, but there are so many potential pitfalls, we all have to work together (good or bad). :)
 
You must log in or register to reply here.
Top