Monday morning seems as good a day as any to address a concern that my team and I have had for some time: automatic coding.
There have been quite a few reports that have come to our attention lately regarding the issue of auto-codes. I’m sure many of you are aware that the U.S Department of Health & Human Services’ Office of Inspector General (OIG) has started to steadily crack down on those physicians who are inappropriately using auto-generated data features within their EHR systems.
So let’s make things clear. While Valant provides our customers with a Mobile Notes module that fast-tracks the entire clinical note and documentation process, with worksheets and tables built into templates that auto-populate previously captured measures and clinical data, we do not (I repeat again for emphasis) we do not offer auto-coding features.
There is a reason for this. As clever, as intuitive, and as revolutionary as I believe our EHR software is, no technology can take the place of good old fashioned medical decision making. So, while those EMR’s with auto-coding capabilities do a good job of telling you how high you can bill based on what you have documented, they do not do a good job of determining medical necessity. Auditors, on the other hand, don’t have a problem with telling you that the work you did was not justified – and taking money back if they deem the work to not be medically necessary.
Here at Valant, we believe that, with the right tools (and education on how to use these tools), our clients can tell the difference between a 99213, a 99214, and 99215. They (you) simply don’t need us to make a big investment in logic that makes the documentation system rigid and less usable…
At the end of the day, what you need is a system that allows you to efficiently and completely document so that you can sleep well knowing that you will sail through an audit.
AUTHOR: David Lischner