EHR Documentation Must Meet the Same Standards as Paper
by Ronda Tews, CPC, CHC, CCS-P
Inadequate documentation is not new to coders, but as offices transition from paper to electronic health records (EHR) coders have a new opportunity to educate physicians when they say, “Oh, that’s documented, it’s just in a previous visit.”
The EHR must follow the same documentation requirements as the paper chart. It is not true that if the information is located “somewhere” in the EHR, that it may be counted toward the documentation requirements for any and all dates of service. The provider must reference within her note for that date of service if she has reviewed any information within the EHR to get credit for the information.
Here’s how Medicare carrier Wisconsin Physician Services (WPS) addresses this topic in a Q&A:
Q 17. This question pertains to an Electronic Medical Record (EMR.) We have always been taught that the progress note “stands alone.” When we are auditing physician’s notes to determine if they are billing the appropriate level of service, what parts of the EMR can be used toward their levels without requiring them to reference it? We are referring specially to Growth charts, Past, Family, & Social History, Medication Listings, Allergies, etc.
A 17. If the physician were not referencing previous material in the EMR, then the information would not be used in choosing the level of E/M service.
The old adage still applies to the EHR: If it’s not documented, it wasn’t done.
Templates are beneficial, but can create problems if documentation begins to look the same for each patient. The Office of Inspector General (OIG) has warned, “Documentation is considered cloned when each entry in the medical record for a beneficiary is worded exactly like or similar to the previous entries…. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter.” This does not mean that providers cannot use templates, but appropriate changes need to be made to the template based on the patient being seen and the treatment provided.
And remember: The volume of documentation doesn’t determine coding, medical necessity does. National Medicare policy asserts, “It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed” (CMS Transmittal 178, Change Request 2321, May 14, 2004).