Improving Medicare Documentation
with Electronic Medical Records

An electronic medical record (EMR) system can help any medical practice improve the quality of its documentation and record keeping. For practices that serve Medicare patients, an EMR can also help facilitate better Medicare Risk Adjustment (MRA) coding practices and prepare practices for periodic reviews and data validations.

An EMR system can help practices avoid some of the most prevalent errors in MRA documentation and coding. For example, an EMR can support a practice’s proper use of ICD-9-CM diagnosis codes to the highest level of specificity, as is required under MRA. (Some systems will even prefill an ICD-9-CM code based on the diagnosis information entered.) In addition, an EMR system eliminates legibility problems, which medical record reviewers consistently note as a barrier to good coding practices.

However, using an EMR doesn’t eliminate all potential documentation errors. Humana’s MRA medical record review team offers the following recommendations for practices using an EMR:

• Everyone in the office needs to be fully trained and use the system in a consistent manner. An EMR is a significant investment; make sure the staff is using it to its full potential and that the practice is gaining efficiencies through its proper use.
• Documentation is only as good as what is being entered. Staff members entering data into the system still need to verify that information is complete and accurate. That includes:
  - Ensuring that electronic signatures are included.
  - Verifying that selections from drop-down boxes match information entered in other areas and that the selection is appropriate for that patient encounter.
  - Checking selected ICD-9-CM codes for accuracy and appropriateness.

EMR systems don’t simply provide record-keeping benefits; they can also improve patient care by reducing potential for medical errors and providing clinical staff with more time for patient interaction. Clinical care staff benefits from faster and easier access to patient records and lab results, and physicians can access information from a hospital, clinic or off-site.

For more information about making the EMR decision, visit the American Health Information Management Association Web site at www.ahima.org/medicalcoding/electronic_medical_records.asp.

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