Wiki ER E/M Calculator Findings

[mlkeathley]

Good morning! I am an outpatient CDIS and am trying to determine if it is appropriate for Emergency Room physicians to copy their E/M Calculator findings into their note to support the level they assigned? We have mixed feelings about it and I cannot find any source that addresses this. Thank you!

 

[csperoni]

I do not have any official source for this, but my instinct goes against this. The medical records are just that - MEDICAL RECORDS and should reflect the care provided to the patient. Coding tools are not part of the care provided to the patient.

 

[amyjph]

It depends I think. If talking pro-fee and not facility. It would not be a good idea to put it directly into the note/medical record for the reason Christine gave above. However, it *might* be okay if it was housed somewhere else within the patient's record, maybe within the charge or superbill area depending on what the EMR/EHR is. I have seen calculators in other areas before. The record documentation should stand alone and support the billing for the services, not a calculator being copy/pasted into it.

 

[jpipke]

It has always been a Compliance issue for codes to be included in the documentation as it can be considered misleading; code assignment is to be based upon the providers' documentation only. For that reason, I say that they should not copy the calculator information into the note especially if the calculator's findings are based upon check boxes that the providers determine themselves, then for sure I wouldn't consider it.

JP - CPC, CPC-I
Clinical Documentation Specialist

 

[keke74]

While EMR E/M calculators can be useful tools to assist with determining the level of service for billing or coding purposes, they should not replace the actual documentation of the patient encounter. The provider should continue documenting their clinical thought process, history, exam, and decision-making in a clear and detailed manner. Documentation is a legal record. If a provider relies solely on a calculator, it may not capture all the necessary information required for audits, insurance reviews, or potential legal matters. I definitely think this would carry a high compliance risk. I would suggest discussing this issue with your compliance department.