Written by: 
Nancy M Enos, FACMPE, CPMA, CPC-I, CEMC 
The benefits of Electronic Health Records – a coder’s perspective
Many physicians have been taught to fear a coding audit, and intentionally undercode in an effort to stay under the radar.  This leaves the physician two problems: lower reimbursement, and incorrectly coded claims.

The use of an electronic health record provides structured notes, eliminating the risk of omission of documentation required for higher level Evaluation and Management (E/M) Codes. For example, a new patient visit with a new problem, resulting in a moderate risk (two or more stable chronic illnesses, an undiagnosed new problem with an uncertain prognosis or an acute illness or complicated injury) should be reported as a 99204.  The American Medical Association (AMA) promotes “risk based coding”, where the Medical Decision Making matches the level of the code reported.  For many new patient visits, this means a level 99203 for low risk and 99304 for moderate risk.

How does a physician ensure that the History and Exam components meet the criteria for the level of medical decision making, and code correctly?  An Electronic Health Record is the answer.  The templates offered by an EHR guide the physician to capture the required information. The History of Present illness is the most important statement, as it sets the stage for justification of the extent of the exam.  The Review of Systems should also be supported by the chief complaint.  Past, Family and Social History are easily captured or confirmed in the EHR. 

The level of exam can be documented by the 1995 (general) or 1997 (specialty) guidelines. It is easier for pertinent negatives to be documented electronically.  Beware of overdocumenting using an “auto-negative” feature if all areas are not examined.

Calculating the type if decision making is often confusing. By providing a template field to capture assessments and diagnostic statements, orders and a plan, the “points” can be calculated and the type of medical decision making can be selected.

In addition to the coding values, the EHR also eliminates illegible handwriting which counts against a physician in an audit.  If it wasn’t documented, it wasn’t done.  If it cannot be read, then it was not documented.