Medical coding and EMR

written by Ricci Mathew

What is EMR and what does it have to do with the medical coding process? EMR stands for "Electronic Medical Records" and is a system that is used by doctors and hospitals to electronically store and manage patients' medical histories. Today because of the Government regulations (like HIPAA compliance) all patient records have to be handled with the utmost confidentiality.

The huge and growing database of medical information has given rise to the development and use of the sophisticated electronic medical records systems which is good for the insurance companies, doctors, hospitals and also for the HMO (Health Maintenance Organization). Handling of huge quantities of medical documents efficiently in less time is made possible because of EMR.

Medical coding is about assigning codes to the diagnosis and various procedures used for reimbursement from insurance companies and government agencies, software companies and consulting firms. EMR is a necessary base for medical coding. Physicians and doctors find EMR to be a very powerful tool that allows complete medical documentation in an easy manner. Many payers and other agencies like Medicare have to keep checking up if the medical coding has been done rightly or if there has been a mistake. This process of checking can be done and is supported only because of EMR implementation.

However indiscriminate use of EMR can result in major errors and so caution must be taken to avoid mistakes in the medical billing process. These are,

- Checking the software's default settings and override whenever necessary.
- Personalizing records as much as possible.
- EMR training for all.
- Maximize human intervention in choosing the codes