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).


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8 Responses to “EHR Documentation Must Meet the Same Standards as Paper”

  1. Janet says:

    I find the hospital EHR’s so incredibly difficult to audit. The format when printed for audit are fragmented and include multiple pages of labs. I really dislike the EHR. I find many more deficiencies due to taking short cuts with the false belief the EHR is a better record.

    Dictated notes are the best and honestly I doubt they are that time consuming considering how many providers are keyboard challenged!

    thanks for the article.

  2. Valerie henderson says:

    I do many authorizations and have difficulty getting approvals when follow up visits all to often documented as ” no changes, requires will obtain auth for treatment”. I have to catch these errors on the same day to inform the doctors o please clarify which is difficult at best. Doctors need to take a cource in documentation and coding, the spend time in billing to trully understand the challenges billers go through. Thanks for the article I will be distributing it to our providers.

  3. Heather Anderson, CPC says:

    We have found that using a scribe is the most efficient in office tool we have for documenting a patient visit. Since Drs often go over so much in the visit, they will often miss adding information to their documentation. Using a scribe in the room with the Dr & patient during examination documents clearly all information Dr goes over with the patient, without obstructing the visit for dictation or Dr typing his own notes (which many patients feel is rude & an interruption to their visit). It allows the Dr not to have to remember everything from the visit afterward as information often will get left out. I really feel with the new EHR system has paved the way for many electronic formats and created a new field of transcription. Having a scribe in the visit has allowed us to give more quality time to our patients, while correctly documenting the visit for coding & effectively utalizes our EHR templates.

  4. Meg says:

    This has been one of my problems since our office when to the EHR. There is way too much copying and pasting, which causes things to get billed that weren’t done at that office visit but was done at the previous one. Not to mention when you try to explain this to the physicians they don’t listen to a single word you say. And don’t even try to talk to the managers, they just sweep it under the rug. All in all this has been one huge nightmare. Hopefully one of these days those auditors will pull in the parking lot and get it all straight for them because I am no longer going to worry about trying to make things right when no one else cares.

  5. Carol Courtney says:

    EHR’s are a wonderful tool if the physician has a hand in helping to build or modify templates. Otherwise you have to get them to buy into the new system which can be difficult. Many phsycians don’t or won’t take the time to fully document a visit . As coders we must take our physicians by the hand and show them the errors of their way. If we just let errors continue, then our AAPC code of ethics has no value and we are setting ourself up to being included in an audit and possibly being put on the Medicare exclusionary list. Every practice should have a compliance program that includes chart audits. Get the audits done for each doctor, then sit them down and do a one on one with each physician (include their nurse or MA if possible). Praise them for what they are doing right, then give them suggestions as to how to improve an area that is done incorrectlyshowing them in black and white what they are doing and why it is incorrect – provide federal regulations that show the cost of the fines. Also, show them dollar amounts that they are losing by cutting and pasting. Doctors understand money and will do the documentation if they understand the impact on the bottom line. Always start with the most damaging documentation and work from there. Don’t try and throw too much at your doctors at once. .

  6. Shannon says:

    To Meg, aren’t you worried that when the auditors come, you will get in trouble as a biller/coder?

  7. Debbie says:

    Meg, read your post, sounds like the place I USED to work at…no matter how many times you went to the billing supervisor (Who was not a certified coder) and told her that the documentation was horrible and we are billing things we should not, she would just say we had to bill what ever the doctor had on the bill slip. Well, I wouldn’t and thats why I say USED to work there.
    Don’t worry they will get in trouble sooner or later.

  8. Jan says:

    Meg – just make sure you document all your conversations with the managers/physicians. Then, when your office does get audited, you have proof that you did attempt to get things done correctly.
    You might lose your job because of office politics, but the physicians will be the ones paying the fines and possibly worse. Wouldn’t we all love to work at a place where all these things are taken seriously and everyone wants things to be done correctly.

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