6. Electronic over-documenting
Closely related to the cloning problem is over-documentation, also called "exploding notes." If your EHR template inserts: "abdomen no tenderness, rebound or masses," into every patient's record, then you'll appear to be disregarding medical necessity. Coding consultant Nancy Enos calls it "the EHR effect."
"With one click on the template, physicians can make every system automatically negative and then go back and just put in what's positive, which leads to over-documentation because you aren't really reviewing every system for a sore throat," Enos says.
Over-documentation also can be a sign of overusing the EHR's auto-populating feature, says Buckholtz.
"We used to tell doctors they weren't documenting enough. Now, it's at the other extreme," she says. "And (insurance) carriers are starting to take notice."
The surest sign of EHR-caused over-documentation? Your visit records jump from one page to three or more pages after you implement the system. The solution, Buckholtz says, is to take care in building templates. A cardiologist should not use the same exam template for a 50-year-old male with chest pains and a pediatric patient with a possible congenital heart condition. Also, make sure that your templates allow you to easily mark off things you aren't doing in the exam.
7. Overlooking CPT updates
Along with introducing new codes and retiring others, annual updates to the AMA's "Current Procedural Terminology" (CPT) frequently add details to required documentation. Enos points to the several dozen codes OB/GYNs and orthopedists use to describe soft tissue. In the latest CPT update, 41 new codes describe size prior to excision or removal.
"The code description now requires more details in the operative note, but I see many physicians who haven't gotten the message yet, so their coders are forced to default to the lower-level code when there's nothing in the record about size," Enos says.
For example, a vaginal hysterectomy of a uterus greater than 250 grams can be coded as CPT 58290 (added in 2003), which pays a Medicare physician $1,127.28 (national average). Neglect to record the weight in your note and you'll likely get the lower code, a 58260, which pays $320.07 less. Failing to note whether a tumor or vascular malformation is more or less than 1.5 centimeters before removing it from the soft tissue on a finger or hand could cost you $79.02, the difference between a 26115 (1.5 centimeters or larger) and a 26111 (smaller than 1.5 centimeters), Enos [email protected]@
8. Confusing the coder
Most coders are not clinicians, says Kim Snyder, corporate director of coding at Zotec Partners. So it's crucial to accurately document the service or procedure you perform. Until your coder is experienced in your specialty, document with the CPT's take on things in mind. For example, an inexperienced coder would struggle to translate a radiologist's note about a "magnetic resonance cholangiopancreatogram procedure without contrast" into a 74181. The CPT guide describes that only as "Magnetic resonance (e.g., proton) imaging, abdomen; without contrast material(s)," saying nothing about cholangiopancreatography.
Snyder, whose firm provides electronic billing and practice management software, says complete documentation is critical to support the application of the appropriate CPT codes that will avoid unintentional downcoding.
Coming Soon to an Audit Near You
Want to know what Medicare's auditors will be looking out for each year? You need only read the Department of Health and Human Services' Office of Inspector General's (OIG) annual work plan. In this document, the OIG details which types of healthcare-related frauds, abuses, and errors it plans to focus on during the federal fiscal year (which starts in October). Here's a sampling from the FY 2010 plan, available at the agency's Web site:
Place-of-service errors. The OIG wants to determine whether physicians are properly coding for services provided in outpatient departments, such as ambulatory surgical centers, which, when facility fees are added, may pay physicians more than inpatient services.
E&M services during global surgery periods. The government wants to know whether the number of E&M services provided during the global surgery period has changed since the global fee concept — under which physicians are paid a lump sum for providing the various services considered part of the global period — was developed in 1992.