EHR Shortcuts Cause Medical Necessity Support Issues
Electronic medical records have simplified documentation and record tracking. In some cases, the electronic record allows the physician to bring forward, or to ?cut-and paste,? previous patient information.
Although physicians may seem to be a wonderful time saver, progress notes are critical to successfully support the reasons for continued hospitalization. Documentation short cuts can create difficulty in supporting medical necessity for the patient?s continued inpatient status.
For example, if the patient?s improvement and/or regression is not documented in a dedicated note each day, the payer rightly may question whether services are medically necessary. If the notes do not indicate clearly the reason(s) for the patient?s continued inpatient status, the payer may deny some of the days as medically unnecessary.