DaVita® Medical Insights

The Good and the Bad with EHR Systems and Coding

As digital technology advances, our world of health information continues to rapidly evolve. The transition from paper records to electronic health records (EHRs) creates an almost seamless flow of information within a digital health care infrastructure. With strict coding and documentation guidelines and evolving new regulatory measures such as meaningful use, MACRA and MIPS—the transition to EHRs has become a critical aspect in capturing the required data for reporting, billing and compliance. However, it has also created new risk areas pertaining to coding and appropriate documentation.

The Good

In theory, EHRs offer the opportunity for improved patient care, more efficient practice management, and improved overall public health. Under perfect circumstances EHRs should save time for physicians and their practice staff by utilizing specialty specific templates geared towards their unique practice.

The Challenges

The transition in documenting patient care from paper charts to EHRs presents challenges from a coding and auditing perspective. EHR systems have made it easy to create a patient file with just a few clicks. With this ease, it appears that overall services are generally being billed at a higher medical decision-making level than before EHR use. One hypothesis for this trend could be due to a physician’s capability to document more data electronically than was possible previously with paper records. It is now easier for physicians or their staff to copy documentation from a previous visit or just check boxes without necessarily addressing these specific areas with their patient in an appropriate manner. Recent studies have shown that only about 20 percent of documentation is original; certainly an unintended consequence of EHRs. With paper, physicians had the saying “if it wasn’t documented, it was not done,” but now with EHR use increasing we are finding that the concern is “you documented it, but can you prove you really did do it?”

As many physician payments are based on severity of illness, correct and specific diagnosis coding becomes even more important. With the transition to ICD-10, the need for increased specificity requires more documentation to support the detail of what was coded. Auditors are finding that when physicians began the transition to ICD-10, they were more specific with the stage and/or condition. However as time passed the documentation now seems to be trending back to having less clarity, and the ICD-10 codes being utilized are less specified. EHR systems help the physician review the conditions for which the patient has been previously diagnosed, but this creates audit risk if the physician does not document in his or her note the specific condition(s) that he or she is managing. It is important to improve the accuracy of documentation so that records accurately reflect the acuity of the patient and the treatment that patient receives during each specific visit.

Medicare contractors have identified what they believe is an increased frequency in identical documentation for each visit by a physician due to the ability to copy and paste a note from the patient’s previous visit. The issues with utilizing the copy and paste function include that the information can be outdated or redundant, it generates unnecessarily lengthy notes and it creates the appearance of fraudulent activity by the perception of billing twice for the same work. Due to increasing use of the copy and paste function, the HHS Office of Inspector General and other auditors are targeting and reviewing physicians’ documentation for multiple visits with the same patient to determine if the documentation contains information to support that the physician saw the patient on each day.

With more intense scrutiny by Medicare and other payers of physicians’ documentation and coding, it is important to consider regular coding reviews to help identify invalid documentation and incorrect coding—whether this is up-coding or under-coding (and to be clear, in a technical sense, under-coding is just as much of an infraction as up-coding). Auditors can help identify areas where your documentation may raise red flags if Medicare or another payer were ever to audit you, and help educate you on areas where you need to appropriately improve your coding or documentation to be compliant with the guidelines and to adequately bill for the services you provide. It is important to identify any gaps, so you can improve the coding or documentation related to a patient’s visit. Further, monitoring coding and documentation is important, and helps you to stay abreast with guidelines that are constantly evolving.


EHR systems have made our lives easier in many ways, but they have also introduced new risks. These risks can be minimized if you monitor your coding and documentation using certified coding and documentation experts. Federal auditors are on the lookout for outliers. Having a trained eye to help you identify and correct problem areas before inappropriate coding or billing occurs is crucial. These experts can help you identify the areas where there is audit risk. As practices continue to adapt to new technology to capture and bill for the services physicians provide, it is important to continue to identify areas where you or your practice may be out of compliance, and initiate processes that allow you to appropriately get paid for your services and to remain compliant in this ever-changing world.

This content has been republished, with permission, from the Renal Physicians Association.

Suzanne Leathers

Suzanne Leathers

Suzanne Leathers is a coding supervisor at Nephrology Practice Solutions. She has more than 11 years of experience and a RHIT certification, and is a certified ICD 10 CM/PCS trainer. She is passionate about educating practices on how they can improve their documentation, coding and billing to support the services they provide. Twitter: @LeathersSuzanne