Only credentialed medical assistants can enter EHR orders

Only credentialed medical assistants are permitted to enter medication, radiology, and laboratory orders into the EHR to count toward meeting the Meaningful Use thresholds under the Medicare and Medicaid EHR Incentive programs.

Correction: This article was updated on June 12, 2014 to clarify information regarding the eligiblity requirements for certification exams and credentially agencies.

Q: One of my colleagues says that only “credentialed medical assistants” are permitted to enter orders in electronic health records (EHR) per Meaningful Use Stage 2. Can you explain?

A: As of January 2013, only credentialed medical assistants have been permitted to enter medication, radiology, and laboratory orders into the EHR to count toward meeting the Meaningful Use thresholds under the Medicare and Medicaid EHR Incentive programs.

According to Meaningful Use 2 core measure 1, any licensed healthcare professionals can enter orders into the medical record for purposes of including the order in the numerator for the objective of computerized physician order entry (CPOE).

The order must be entered by someone who could exercise clinical judgment in the event that the entry generates any alerts about possible interactions or other clinical decision support aids. This necessitates having the CPOE occur when the order first becomes part of the patient’s medical record, and before any action can be taken on the order.

The Centers for Medicare and Medicaid Services (CMS) did not specify any particular credentialing agency for medical assistants, but did say that the credentialing would have to be obtained from an organization other than the employing agency.

Many working medical assistants have not graduated from an accredited program and thus are not eligible to sit for a certification examination offered by some agencies. The American Association of Medical Assistants (AAMA), the certifying agency for medical assistants, says these individuals are not eligible for certification by the AAMA, but they may be eligible for certification through other agencies.

According to CMS, a non-certified individual, such as a scribe, is not qualified to enter these orders in the computerized provider order entry because there is no licensing or credentialing of scribes, so there is no guarantee of their qualifications for accuracy in such a position.

Documentation required

To qualify for payments under the EHR incentive programs, providers will be required to present documentation of all entries, many of whom are automatically entered by the EHR system.

CMS auditors have the authority to determine the entry of medication. Laboratory and radiology orders have been made by the licensed healthcare professional or credentialed medical assistant.

If the auditors find that the order entry was performed by an individual other than a licensed professional or credential medical assistant, it could constitute a violation. In that case it is possible that the order entry by the individual would not be counted toward meeting the Meaningful Use thresholds.

Consequently, the eligible professional may not meet all the core objectives and as a result would not receive the incentive.

The answer to our reader’s question was provided by Maxine Lewis, CMM, CPC, CPC-I, CCS-P, president of Medical Coding & Reimbursement in Cincinnati, Ohio. Send your practice management questions to medec@advanstar.com.

Physician outcry on EHR functionality, cost will shake the health information technology sector

(Slideshow) Medical Economics EHR survey probes physician angst about adoption, use of technology

Scribes can help document care, boost efficiency at medical practices

Meaningful Use, stage 2: Ready or not, here it comes