HCFA documentation guidelines and the need for discrete data: a golden opportunity for applied health informatics

The medical community is shocked by the complexity of the documentation now required to support the Medicare billing codes. This situation represents an opportunity for Electronic Medical Records that use discrete data to become a central factor at the point of care by fulfilling these stringent documentation specifications.

This empirical study explores whether a discrete data EMR has the ability to generate automatically a report describing what billing code is consistent with the documentation recorded. We tested this hypothesis on HBOC Pathways SMR by attempting to create algorithms that reflected the HCFA guidelines. We validated this process using historical records from the Cleveland Clinic.

All the data elements required by HCFA were available as discrete data. Using algorithms, the billing code consistent with the documentation of the health care encounter could be automatically generated.

EMRs using discrete data can substantially reduce the burden placed on health care providers by HCFA's new documentation guidelines. This benefit creates a window of opportunity for health informatics to become an integral tool in the provision of health care. Using EMRs for billing purposes can help achieve the loftier goal of using EMRs for quality improvement.