EPIC Medical EHR Tips

As the landscape of medical coding evolves, accuracy and compliance remain crucial for healthcare organizations. With new CPT 2026 code updates, advancements in digital health, and the growing role of AI, coders face increasing complexity. This guide covers expert tips to boost medical coding accuracy, prevent documentation errors, and keep revenue integrity intact. 1. Stay Informed on CPT 2026 Code Updates Regularly reviewing CPT 2026 updates ensures coders remain compliant

Flat lay of revenue report with a calculator, pencils, and notebook. The pressure on hospital-based coders working in high-acuity areas like emergency departments, observation units, and infusion centers is immense. Every keystroke, every selection within the electronic health record (EHR), directly impacts the facility’s financial health. When documentation falls short, revenue integrity suffers immediately. For those navigating the complexities of EPIC documentation, ensuri

Can you bill multiple initial IV infusions codes in the same encounter? Generally, coding guidelines allow for only one "initial" infusion code per encounter. However, reporting two initial codes (e.g., CPT 96365 and 96365-59) is permitted when it is medical necessary for separate IV access and it is clearly documented. This usually occurs due to medication incompatibility, high-volume resuscitation, or specific drug protocols. In this guide, we will break down how to use Epi

The Epic MAR is a clinical safety tool, not a billing sheet and treating it like one is an audit waiting to happen. Learn the 5-step dissection process to move past the 'clutter' of auto-documentation and capture defensible charges. From 'Technical Pauses' to 'Provider Intent,' discover why the MAR is never enough on its own and how to cross-validate your data for total compliance.

Why “Given” in Epic Does NOT Automatically Mean Billable Excellent and crucial question. This gets to the very heart of your role as a charge capture specialist. In Epic (and most EHRs), the status "Given" is a clinical documentation point, not a billing trigger. It means the medication was administered to the patient, but it does not mean it meets all the complex rules for professional or facility billing. Here’s a breakdown of why "Given" doesn't equal "Billable," focusing