Physicians sometimes struggle to implement an electronic health record system into their practice. Eventually, they became proficient using their EHR — and come to appreciate the short cuts it makes possible, while being resigned to its quirks. One of the pitfalls of using an EHR is that notes tend to take on a certain uniformity or sameness. Using templates and preformatted text and carrying forward information from a previous visit should save the physician time, ease documentation burdens, and benefit patient care. However, many clinicians are struggling to realize these benefits while not producing notes that are overly templated and uniform. In other words, ones that appear identical to other notes.
While Medicare is actively encouraging physicians to implement EHRs, the Office of Inspector General (OIG) included "identical notes" as an area of interest in its 2011 Work Plan. Recovery Audit Contractors saw a good deal of identical notes from one patient visit to the next, and also, portions of the note that are copied from one clinician to another.
Payments for Evaluation and Management services:
We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS's Medicare Claims Processing Manual, Pub. No. 100-04, ch. 12, 30.6.1 instructs providers to "select the code for the service based on the content of the service" and says that "documentation should support the level of service reported." Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same provider and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments.
When is it OK to copy?
What is legitimate to copy from note to note? The Documentation Guidelines were developed in 1995 and revised in 1997, before EHRs were in common use. However, they are still in effect and serve as our guidance about what parts of the note may be recorded by someone other than the billing clinician and what components from a previous note may be reviewed and credited without re-documentation.
DG: A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. The review and update may be documented by:
• Describing any new ROS and/or PFSH information or noting there has been no change in the information; and
• Noting the date and location of the earlier ROS and/or PFSH.
DG: The ROS and/or PFSH may be recorded by ancillary staff or on a form completed by the patient. To document that the physician reviewed the information, there must be a notation supplementing or confirming the information recorded by others.
Telling the whole story
The key points: If someone other than the billing provider documents these portions of the history, the provider must review that with the patient in order to get credit. And, past history copied from a previous record needs to be reviewed, not simply dropped into the note. Only the billing provider may document the History of the Present Illness (HPI).
"I have no idea why this patient was sent to me," a specialist complains. "What does the cardiologist recommend? I can't tell from this note," observes a PCP. This is a frequent complaint, and occurs because the progress note does not tell a story about the patient's condition and the treatment plan or clinical thinking.
How can a clinician enjoy the benefits of an EHR while avoiding the pitfalls of cloned or identical notes?
• Always document the history of the present illness based on the patient's description that day — never copy it from a previous visit.
• Only use review of systems categories that are relevant to that day's visit. Avoid copying all of the ROS from a previous visit.
• Only use past medical, family, and social history from a previous note if it is reviewed with the patient and relevant to that day’s visit.
• Use normal templates with care, and edit these thoroughly.
(Here's a useful exercise. Remove the patient names from a sampling of notes and ask your clinicians to review their own and other's notes. Can the clinician treat the patient based only on the note? Does the note tell the whole story?)
Betsy Nicoletti is the founder of Codapedia.com. She is the author of “A Field Guide to Physician Coding.” She believes all physicians can improve their compliance and increase their revenue through better coding. She may be reached at [email protected] or 802 885 5641.