With Ambulatory EMR implementations at an all time high, organizations are looking at ways to streamline the clinical workflow. Physicians are embracing EMR technology, but one aspect of the application is not always bullet proof; the coding module. Regardless of the EMR, the way coding is calculated in the EMR has to do more with science than art. However, physicians know when the complexity of visit warrants a higher code and when the visit was just a routine occurrence. The level is often subjective and therefore is not easily interpreted by a simple software algorithm.

The number of ”counts” the software makes given the HPI, orders, meds, and problems, will calculate the complexity of the code.  All too often coders audit the EMR and are not able to understand why a visit was coded at a higher level. The calculations vary by coding module (EMR vendor), but basically it is a simple tally of the documented events. The provider looks at the coding “suggestion” at the end of the visit and must determine if it is correct. The judgment is left for the person signing the note.

Keep in mind that in the rush to get to pre-EMR productivity levels, some providers will go with whatever the software says and sign off. It takes too much time and too many mouse clicks to go back and change it. We must make it easy for providers to downgrade the level of the code to meet their subjective judgment call. 

You cannot make a blanket policy to say that the coding software will be used exclusively. This is like telling a pilot to trust their instruments, although the ground is getting closer and closer. Figure out a way to allow your providers to accurately code, it will be much more expensive to do it after an audit.