From Paper to EHR, “Detailed” Means “Detailed”

By Ronda Tews, CPC, CHC, CCS-P

Contrary to any rumors you may have heard, the electronic health record (EHR) must follow the same documentation requirements as its predecessor, the paper chart. If a detailed history is required to bill 99214 or 99203 in the paper record, it is still required to report 99214 or 99203 when documenting with an EHR.

It is not true that if the information is located “somewhere” in the EHR it may be counted toward the documentation requirements for any and all dates of service. The provider must reference within his or her note for that date of service if he or she has reviewed any information within the EHR to get credit for the information.

For example, if the provider does not document any past medical, family, or social history (PFSH) within his or her note, how would an outside auditor know there is PFSH in the EHR; and how would the auditor know the provider reviewed the information on that date of service? The auditor wouldn’t know, and wouldn’t likely go looking for the information or assume the provider reviewed it.

Here’s how Medicare carrier Wisconsin Physician Services (WPS) addresses this topic in a Q&A (see www.wpsmedi​

“Q 16. 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 16. 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.”

TrailBlazer addresses the same topic in a document titled “Part B Tips for Preventing Most Common E/M Service Coding Errors:”

“All history obtained and recorded by triage and other hospital nursing staff must be specifically repeated by the physician and either re-recorded or annotated with specific comments, additions, and/or corrections and notation of the elements of work personally performed by the physician.”

The old adage still applies to the EHR: If it isn’t documented, it wasn’t done.

EHRs Bring Unique Benefits, Challenges

Many providers were told the EHR was going to make their lives simpler by cutting down on documentation time. This is somewhat true because the EHR allows providers to have test results at their fingertips, and instant access to patients’ previous visits by all providers tied to that specific EHR. Documentation of the visit has proven to be a bit more tedious for most providers, however.

Templates are beneficial, but create their own problems. For instance, a provider may have a template created including a review of systems (ROS) and examination. The provider pulls this template into every note to save documentation time, but in the business of her day may not make appropriate additions and/or deletions to the template based on the patient’s presenting problem(s). As a result, the documentation begins to look the same for each patient and may contain conflicting information. For example, the note may say, “The patient presents for runny nose, cough, and sneezing,” yet the ROS template may say “ENT: Negative for congestion, sneezing, postnasal drip, ear pain, or sore throat.”

As a result, 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. Cloning also occurs when medical documentation is exactly the same from beneficiary to beneficiary. … Cloned documentation does not meet medical necessity requirements for coverage of services rendered due to the lack of specific, individual information. All documentation in the medical record must be specific to the patient and her/his situation at the time of the encounter. … Identification of this type of documentation will lead to denial of services for lack of medical necessity and recoupment of all overpayments made.”

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 being performed. The provider’s comprehensive, 10-system ROS probably is not necessary for a patient who presents with a sore throat, but may very well be needed for a patient presenting with chest pain.

Documentation Volume Doesn’t Determine Coding, Necessity Does

As our Medicare carriers begin to see the beefed-up documentation EHRs allow, they may place restrictions or limitations on requirements to bill the higher-level evaluation and management (E/M) codes.

For instance, TrailBlazer (Medicare carrier for Texas, Oklahoma, Colorado, and New Mexico) has stated in “Documenting Components of an Established Office E/M Service,” “Do not record unnecessary information solely to meet requirements of a higher-level service when the nature of the visit dictates a lower-level service to be medically appropriate” [emphasis in original]. This mirrors national Medicare policy, which 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 (CR) 2321, May 14, 2004).

Watch Out for Lists

Diagnosis coding also faces new challenges as a result of EHR implementation. Some EHRs have the capability of bringing in the patient’s established problem list to each visit. This is fine, as long as the provider is treating each one of those established problems on that date of service and documentation supports all diagnoses billed for that date of service.

For example, a patient is seen for a minor, acute problem such as sinus infection, yet the only diagnoses attached to the claim for that date of service are hypertension and osteoarthritis, which were the diagnoses on the patient’s problem list. In this case, the documentation does not support the diagnoses for that date of service. The provider must know how to find the appropriate diagnoses in the EHR, as well as how to attach the diagnoses to the visit. If an established problem list populates within the provider’s note, he or she will need to disassociate any diagnoses he or she does not treat on that date of service.

As EHR adoption becomes more widespread, I believe we will see Medicare carriers crack down on documentation requirements by putting into place and enforcing more stringent E/M documentation rules. Coders and clinicians will do fine, however, as long as they follow the established rules for documenting services in the pre-EHR era. Providers must document everything they did to be reimbursed appropriately—the EHR did not take away that requirement.

Remember: The purpose of the EHR is to improve patient care; and a detailed history still equals a detailed history.



Ronda Tews, CPC, CHC, CCS-P, is a senior financial analyst in revenue compliance for Mercy in St. Louis. Ms. Tews conducts E/M audits for all Mercy providers in Oklahoma. Her duties have included establishing internal auditing and monitoring; teaching coding classes; providing E/M documentation training to providers; implementing compliance education and training programs; and managing the Report Line. She also provides education to physician assistant students at Missouri State University. Ms. Tews has been in the health care industry for over 20 years, and has served as secretary and president of her local AAPC Chapter.


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