Avoid the Dark Side of EHR Documentation

Don’t let the point-and-click mentality entice your time-pressed provider.

By Holly J. Cassano, CPC

Electronic health records (EHRs) promise to make the patient chart more inclusive, more legible, and faster to document. These advantages alleviate many of the headaches of paper charting. On the flip side—or the “dark side,” as I call it—the ease with which EHRs allow time-pressed providers to add information to the medical record, or to bring forward information from a previous note, can lead to an uncritical point-and-click mentality.

Evaluation and Management – CEMC

For instance, most EHRs incorporate tools with defaults such as “reviewed past, family, and social history,” designed to help the provider document more effectively and efficiently. But audit findings show these functions are not always indicated, or even performed, at each visit. If the provider does not review the record and make corrections to the default information, the EHR won’t reflect the true nature of the patient’s condition.

Point-and-click Can Lead to Documentation Danger

Inaccurate documentation poses obvious and very serious health dangers for the patient. More often, however, problems arise not because a provider diagnoses or prescribes incorrectly, but because inaccurate documentation leads to coding or compliance errors, which lead to audits and charges of abuse or fraud.

For example, with EHRs now the norm for the majority of medical providers and institutions, excessive documentation—rather than insufficient documentation—often is the problem. An EHR allows the physician to literally point and click through bullet points and other pertinent criteria, unwittingly navigating to a higher service level than is justified based on the nature of the presenting problem. Such documentation may add up to a high-level service based on bullet points, but fall short on medical necessity. Medical necessity—not medical decision-making (MDM) or any other component of an evaluation and management (E/M) service—ultimately drives coding.

The Medicare Claims Processing Manual, chapter 12, section 30.6.1 (www.cms.gov/manuals/downloads/clm104c12.pdf) defines medical necessity as “… the overarching criterion for payment in addition to the individual requirements of a CPT® code,” while warning that the sheer volume of documentation shouldn’t influence E/M leveling:

“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. Documentation should support the level of service reported.”

Coders who often complain about too little detail might think there’s no such thing as too much documentation. But consider this blog post by an emergency department (ED) nurse :

“The other day at work I was taking care of a patient that was in an MVC. She was in spinal precautions and complained of neck and leg pain. Our ED Physician came in and did his exam from the doorway holding his Tablet PC, marking off items into the Electronic T-sheet while he asked a few basic questions. He was in and out in less than a minute. Out of curiosity, I reviewed his documentation and not surprisingly there was a comprehensive assessment documented. Abdominal findings, lungs sounds, heart sounds, pupils and ocular movements, neuro exam, all beautifully documented in a long paragraph and all normal. Not bad for an exam conducted from the doorway. The same physician had the same general exam pattern on most of his patients and the same comprehensive documentation of his exams.”

This is a good example of the point-and-click mentality. I would venture to say this is the exception and not the rule for providers. But, in my 14 years in this industry, fraudulent and abusive activity has crossed my path on a few occasions. If you encounter this type of behavior at your practice or facility, address with your compliance department immediately.

Cloning Gains OIG’s Attention

A related concern, touched on in the aforementioned blog post, is documentation cloning. Centers for Medicare & Medicaid Services (CMS) contractors have been monitoring supporting documentation of E/M services, and have noticed among EHR users a high volume of records with identical documentation across services. In other words, information from previous encounters is brought forward without updating, which brings into question the validity of the entire service.

Office of Inspector General (OIG) statistics state that Medicare paid $25 billion—19 percent of all Medicare Part B payments—for E/M services in 2009 . Numbers like these get the OIG’s attention. Documentation problems like the aforementioned examples have earned special attention in the OIG Work Plan, which states, “We will also review multiple E/M services for the same providers and beneficiaries to identify electronic health records [EHR] documentation practices associated with potentially improper payments”.

The results of a recent CMS study suggest the OIG will find plenty of E/M documentation problems among EHR users. CMS audited four practices utilizing EHRs, reviewing 20 to 100 charts per physician. Twenty to 90 percent of the charts failed the audit. In the practice with the lowest failure rate, each physician had to repay $50,000. At the other practices, physicians repaid $150,000 to $175,000 each.

The seriousness of coding and compliance errors continues to rise as the stakes get higher for physicians. The OIG has defined health care fraud as an “intentional deception or misrepresentation that the individual or entity makes knowing that the misrepresentation could result in some unauthorized benefit to the individual, or the entity or to some other party.” Changes brought about by health care reform, including new language under the Health Insurance Portability and Accountability Act (HIPAA), now argue that fraud occurs when an individual knows or should have known about improper practices. The language change shifts responsibility to those submitting claims, and assumes that providers have a due diligence obligation to identify and prevent fraud proactively. Providers, practices, and facilities will have to be more vigilant than ever to avoid accusations of fraud if coding and compliance errors are uncovered during a payer audit.

Fight the Good Fight

Knowing the problem areas of EHR E/M documentation and what’s at stake, how do we avoid the dark side?

  • Care and vigilance when clicking through the templates – Take your time: The chart you are documenting may be the one you will be called on to defend on the witness stand.
  • Limit the copy and paste functions – In an audit, copy and past functions can be perceived as cloning. Copy and paste also risks introducing documentation errors. As often as is possible, document in your own words.
  • Review, review, review before closing notes – I can’t stress this enough: Check the meds, the test results, and all interventions with the patient; and make sure that you are in agreement with the story you have depicted of the patient’s encounter. Once you close the note, your only option for a correction is an addendum.
  • Addenda only pertinent clinical information, not just revenue based information – Do not get into the habit of adding documentation to support a higher service level unless the documentation is reflective of medical necessity (e.g., adding information on radiograph interpretations or documenting medication or other interventions that can boost a visit level should be done at the time of service to reflect the presenting problem’s severity).
  • Document your own notes – Do not clone from other providers.
  • Discuss EHR concerns with coders and compliance professionals at your facility/practice — If you notice a deficiency, such as an incorrect ICD-9 or CPT® code that auto-populates, or verbiage that populates a field that is inconsistent with the review of systems (ROS) or the exam, be sure to alert the appropriate staff to have the problem corrected.
  • Review audits and documentation deficiencies to maintain compliance – At minimum, auditing should be done annually. However, a good coder will review every record from an auditing perspective before assigning codes to ensure that the record is accurate.

For example: A patient presents to the ED with a chief complaint of acute abdominal pain. The HPI states that the pain severity is mild, and in the ED it is gone. The record claims that the patient has never had these symptoms before. The record further states there has been no constipation or additional symptoms. The ED doctor indicates that he reviewed the nurse notes and then moved onto the exam. The exam reflects that the abdomen is soft and non tender with no palpable masses, no guarding. The ED physician then orders an EKG, chest X-ray, full labs, a CT of the abdomen with contrast, a CT of the pelvis with contrast, a KUB, a pelvic sonogram, and gives morphine, Dilaudid, Zofran®, and saline as the medication interventions. In the radiographs, it is noted that the colon is full with stool, indicating a mild fecal impaction. A review of the ED nurse note indicates that the pain level is six out of 10 and is burning, that the patient has had nausea and vomiting, that the patient has had these symptoms before, and that the patient has guarding of the lower left abdomen.

The clinical impression states: acute abdominal pain

The patient is discharged home and given a prescription for Colace® and Vicodin, and told to follow up with an appointment with Dr. Gastro.

As we look at this record, we see several obvious problems:

  • The severity of the problem indicated in the HPI (history of presenting illness) does not support the tests and interventions ordered; this undermines medical necessity.
  • The record contradicts itself, stating both that the patient has and has not experienced these symptoms before.
  • The exam indicates that the abdomen is within normal limits, which also suggests a lack of medical necessity for the interventions ordered.
  • The ED physician claimed to have reviewed the triage registered nurse’s notes, but if this was so, he would have seen that the patient presented with acute pain, nausea, vomiting, and guarding of the lower left quarter, which would support an acute abdomen workup in the ED.
  • In the clinical impression, the final diagnosis code is indicated as “acute abdominal pain,” but acute pain has not been indicated in the ED physician’s documentation (it is indicated in the nurse’s notes, but you can’t code from that). Lastly, the radiographs reflect a mild fecal impaction, which is not indicated in the clinical impression.

This visit, based on the interventions and workup, may qualify as a high-level ED visit (e.g., 99285 Emergency department visit for the evaluation and management of a patient, which requires these 3 key components within the constraints imposed by the urgency of the patient’s clinical condition and/or mental status: A comprehensive history; A comprehensive examination; and Medical decision making of high complexity). Unfortunately, the ED physician’s documentation is not supportive of either this coding or the workup provided. More than likely, the ED doctor clicked-through the HPI and the exam and other pertinent areas out of habit and thereby missed documenting the correct information in the chart.

As a coder, it’s your responsibility to speak to the ED doctor about inconsistencies in the record. EHRs are great tools, but used carelessly they can lead to the dark side. To bullet proof documentation in the event of an audit, it’s imperative for the provider to document in an EHR the true clinical picture and correlating E/M level supported by medical necessity for appropriate level assignment and to lessen the potential for errors in patient care.


Watch for EHR
E/M Documentation No No’s

When using EHRS, here are the primary E/M documentation pitfalls to avoid:

  • Templates and billing driving care and charting
  • Point-and-click mentality vs. accurate and ethical documentation
  • Copy and paste forward
  • Charting for services that were not performed: use of default entries
  • Documentation cloning
  • Negatives listed vs. positives—hard to discern what is wrong with the patient
  • Failure to review available information
  • Inaccurate charting
  • Addendums for increased reimbursement vs. for patient care
  • Relative value unit (RVU)-driven care
  • Signing of notes without reading them
  • EHR revealing bad practice patterns


Holly J. Cassano, CPC, has been involved in practice management, coding, auditing, teaching, and consulting for multiple specialties for the past 14 years. She served two terms as an AAPC local chapter officer and has written several articles for Justcoding.com and writes a monthly column devoted to fighting fraud for Advance for Health Information Professionals. She is the coder and physician educator for the emergency room physicians/bariatrics at the Cleveland Clinic Florida.


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