AHIMA calls for coding guidelines

Vendors, users need code of ethics

Electronic health records, when used correctly, produce more accurate documentation leading to more complete coding, and ultimately, more accurate reimbursement claims, according to Sue Bowman, senior director of coding policy and compliance of the American Health Information Management Association.

Bowman presented May 3 at a listening session hosted by Centers for Medicare & Medicaid Services and the Office of the National Coordinator for Health Information Technology at the Department of Health and Human Services, according to a news release issued by AHIMA.

The session, “Billing and Coding with Electronic Health Records,” convened stakeholders including providers, health association leaders, health information technology vendors and others to discuss EHRs, increased billing for some services and appropriate coding in an increasingly electronic environment.

[See also: AMA: EHRs create 'appalling Catch-22'.]

During her presentation on developing EHR coding standards, Bowman called for more research on the causes of higher levels of coding and reimbursement, the statement said.

“The extent to which EHRs have led to improper reimbursement is unclear,” Bowman said. “EHRs produce more complete and accurate documentation, and this could be leading medical providers to seek reimbursement for services they have always been providing but weren’t properly documenting before. Higher levels of reimbursement do not necessarily equate to fraud.”

EHRs offer many benefits, including saving time, prompting clinicians for documentation, and improving consistency and completeness in medical records, said Bowman. On the other hand, they also have some features that can be risky if improperly used, like copy/paste, auto-creation of default documentation and templates with limited options.

“If EHR systems are not properly designed and used, they can lead to inaccurate, outdated or misleading information,” said Bowman. “That’s why all EHR users should receive comprehensive training and education on how to use them correctly. Real improvements in documentation and coding should be rewarded, and misuse should be punished.”

To address the problems concerns about EHRs, AHIMA made several recommendations, including:

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