Possible Pitfalls of Auditing Electronic Medical Records

Event Information
Product Format
Prerecorded Event
60 minutes
Product Description

Identify and Remove Issues with Your Electronic Medical Records Before They Create RAC Audits for Your Physicians.

As auditors you need to be keenly aware of potential problems with EMR systems. If your EMR system is programmed to choose the level for the physician, or allow cut and paste, these are just two of many areas that could create RAC audits for your physicians. You want to safe guard your physicians and make them aware of why, how and what to identify potential problems with EMR systems.

Physicians have been burdened with EMR systems. They are seeing fewer patients these days, therefore its affecting their reimbursements. They need auditors, coders and others to help them make sure their systems are working to their benefit. 

Expert speaker Melody Irvine in this 60-minute session, will help you identify and remove potential issues before they become problems for you and your physicians. Melody will look at all the possible grey areas of EMR—terminology, drop down boxes, medical necessity and others—that could hold potential problems in the future.

Topics covered in the session:

  • Copy and Paste and potential risks – how does DHHS, Medicare and even attorneys view the copy and paste features
  • Medical Necessity – Does your computer have a human brain to decipher medical necessity? If the physician performs a comprehensive history and exam with low medical decision making, the EMR may code this as a 99215 and these kind of practices put physicians in a high-risk category for RAC audits
  • Upcoding or coding higher than medically necessary can have it’s consequences.
  • Risks with EMR for History, Exam and Medical Decision Making
  • How are the grey areas deciphered in your EMR system?
  • Are chronic problems that were not addressed during the visit counted for?
  • Get heaps of examples that have been identified with EMR systems
  • Difference between EHR and EMR
  • Risk audits with EMR
  • Insights on what OIG says
  • Discussion on common potential problems with your EHR

Session Agenda:

  • Areas of risk with documentation
  • Cut and paste/cloning of medical records
  • Terminology/Buzz Words/Free Texting
  • How it could affect history, examination and medical decision making
  • Medical necessity
  • Common problems identified

Who should attend

CPC, CPMA CEMC, Compliance Officers, Auditors


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About Our Speaker

Melody S. Irvine - Medical Billing and Coding Expert

Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPB, CPC-I, CCS-P, CMRS, AAPC Fellow, has 38 years of experience in the medical profession. She is the founder of Career Coders Online Medical Billing and Coding School with a specialty in physician auditing. Her extensive background includes director of coding, auditing, compliance, urgent care and billing for a forty-eight multi-specialty physician practice as well as a previous...   More Info
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