One of the growing concerns of the Office of Inspector General (OIG) is the growing tendency among to upcode claims, that is, to code and report encounters as more serious and requiring more costly treatments than they actually do. What’s even more alarming is that the electronic health record (EHR) could be responsible this practice. Medical transcription services can help providers report patient care /visits accurately, streamline EHR use, and reduce audit risks.
Pitfalls of Automated Documentation
- With their cut and paste and keyboard macros, EHRs make the cloning and copying of information easier. The template approach of the electronic medical record (EMR) is rigid and cumbersome, and may not reflect what the physician means. These automated systems may assign codes and generate words that do not really reflect the treatment that the physician intends to provide. This can lead to upcoding or undercoding, both of which are considered fraudulent practices.
- EHRs offer pick-lists that are very cumbersome and time-consuming to manage. The physician has to go through the lists to customize the template to suit each encounter.
- The cookie-cutter style restricts physicians from expressing their actual opinion about a case, which is very important when it comes to accurate diagnosis and treatment.
- The limited information available in a template would be of no use for a physician’s defense in a malpractice case.
- Entering information in the EHR detracts attention from the patient, so that the physician-patient relationship loses its personal touch.
Tips to Improve EHR Use along with Medical Transcription
Medical transcription provides a unique and concise narrative that reflects accurately the findings and recommendations of the provider documenting the encounter. So the solution to streamlining EHR use lies in blending the electronic record with transcripts of physician dictation. As EHRs are here to stay, it’s crucial that physicians receive streamlined training to use them correctly. Here are some recommended tips to enhance EHR use:
- Document the patient encounter and the course of their treatment in legible manner so that anyone reviewing the medical record can understand it.
- Limit use of macros. If used, they should be customized to reflect the patient’s condition.
- Avoid cloning records completely; if the copy forward function is used, the physician needs to review and update the information in the current documentation.
- For present diagnosis, physical examination and treatment plan, the physician should create a unique history at the encounter using dictation possibilities and medical transcription.
Being aware of the drawbacks and challenge of the EHR and how to surmount them is the key to accurate and meaningful documentation of the patient-physician encounter. Partnering with a reliable medical transcription company can help physicians maintain medical records to meet industry regulations.