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Now is the time to be sure our EHR is compliant with auditing and documentation guidelines if an audit comes your way.
EHRs have their pros and cons, but auditing electronic records have identified several obstacles we should be aware of as providers and auditors. Here are a few, of several problems, you might encounter.
• Cut and Paste
• Grey Areas
• Chronic Problems
• Medical Necessity
Cut and Paste
History and examination should be thought out and not appear cloned from the last visit and relevant to the current encounter. Credibility can be compromised when copied and pasted from a previous visit.
Example of cut/paste: It was inadvertently documented the patient was allergic to ciprofloxacin instead of cephalosporin. This can easily happen when making a selection from a dropdown box. This information was then copied and pasted by the consulting physician. Later the drug allergies were corrected, but by that time the note with original error was already copied by other providers and/or traveled to other systems with the wrong information.
The Office of Inspector General (OIG) states “Medicare contractors have noted an increased frequency of medical records with identical documentation across services.” This has also raised a big concern for malpractice issues due to the information copied is incorrect or history and exam is identical to the previous encounter.
How does your EHR view grey areas? Every Medicare contractor has their own guidelines to follow for documentation that is typically followed by commercial payers. Many EHR systems are set up by software companies and not auditors or coders, and can create problems with documentation requirements.
Example-95 examination guidelines: The difference between an expanded problem focused and detailed examination is the word “detail.” What is the interpretation of “detail?” No one, including Medicare can give us a definition of detail to distinguish the difference between EPF and detailed exam. This could make a difference in the level of service. How does your EHR system define detail to make that decision?
Systems are set up to list all the patient’s chronic problems. Some are also set up to count all the chronic problems in Medical Decision Making (MDM). Counting a chronic problem that is not relevant or addressed in that day's encounter could give a higher level of MDM. This could be a problem due to, and considered fraud by, upcoding the level of visit. Unless the chronic problem is secondary to the condition, it cannot be a valid diagnosis for the encounter.
Example: 1st scenario - Patient has diabetes and is seen for an ulcer. The diabetes would be a listed diagnosis even though it was not addressed because it can be a secondary condition that could affect the ulcer. 2nd scenario - Patient has chronic low back pain and is seen in the office for sinusitis. The chronic low back pain is not a secondary issue to the sinusitis and cannot be counted as a valid diagnosis for that days encounter.
How do our computers decipher medical necessity? It does not have a human brain, therefore how it decide if the visit is supported by medical necessity?
Example: Established patient is seen in the office for a boil on their finger. A comprehensive history and examination is performed. A comprehensive history or examination is not required or would it be medically necessary for this type of problem.
This scenario also points to other problems. Does your EHR choose the level of visit for you? It is not recommended to let your EHR choose the level, because of these types of problems. The other problem identified is if the MDM is the lowest component of the three (history, examination, and MDM) it should be the driving factor for the level of the visit. So in the example above, the MDM would be low and therefore so would the level of the visit.
In summary, make sure your EHR system is compliant with auditing and documentation guidelines. It is important to identify any problems before they become a problem with a government or commercial audit.
Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS, has over 30 years of experience in the medical profession. She specializes in physician auditing, education, curriculum development, and consulting services. She is the CEO and founder of Career Coders online medical billing and coding school. Irvine is an approved Professional Medical Coding Curriculum (PMCC) instructor with AAPC. She is also a member of the AAPC’s National Advisory Board. E-mail her here.