The function of EHR is to improve the patient care and reduce the costs associated with it. The downside to it that while using the EHRs it is easier to make errors whether it’s intentional or not and it occurs on a large scale.

Most of the EHR systems would implement macros that allow users to generate a large amount of documentation on a single click. This is called charting and helps in saving lots of time and makes the difficult tasks become less painful. But the user needs to make a careful use of the software to keep it accurate for a particular patient or the user can run the risk of fraudulent documentation.  Many EHRs have a functionality that allows the automatic population of certain parts of patient’s records without relevance to that visit or without providers review; this is known as chart cloning. As a result of it documentation can be created for those services that were not really offered. Upcoding is possible with both these features.

You can be susceptible to suspicion of fraud if you have EHR that automatically generates the codes that are inconsistent with your current level of documentation such as if your EHR tells on how to get higher reimbursement fees or how to generate higher codes or if your patient chart is more strong than it actually was during the patients visit.

Using macro and similar features helps physicians save lots of time spent on documentation and make their jobs look so much easier. But these benefits come with risks and these risks seem to be escalating and the federal has promised to take a closer look at the situation.

You can keep yourself safe against the risk of improper coding by making yourself familiar with the features of your EHR and how to use them safely and effectively. Not all EHRs have the option of auto-population or cloning to maintain the clinical efficiency. Some EHRs are designed in such a way that they avoid the risk of upcoding by allowing providers to capture those elements that populate the patients chart at the point of care without obstructing productivity.

With CMS and other looking for reasons to decrease the payments and with the threat of fraudulent charges hanging over the physician’s heads, it is necessary for physicians to make sure that their documentation is accurate as possible; after all it is the primary goal of EHRs. EHR technology has become an important part of many practices. It is just a tool but how you use it depends on you.

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