Coding from EHRs: It’s Documented, but Did It Happen?

By Erin Andersen, CPC, CHC

The age of electronic health records (EHRs) has begun. The days of deciphering illegible chicken scratches, cajoling busy physicians to write more than 10 words, and extensive searches for missing charts will one day be extinct. The EHR allows coders to work from home, promises a more complete record, timesaving templates and legible notes, and offers hope for better communication between health care providers.

But EHRs bring their own coding and compliance risks. These include:

  • Using entries from another person or source (such as another provider, resident, or student) as their own documentation.
  • Using documentation from a previous visit to document a current visit.
  • Using templates that may not represent what happened at the current visit.
  • Misrepresenting the nature of the visit by carrying forward past clinical data that does not apply to the current visit.

Look for Telltale Signs in the Chart

How do coders know when these things are occurring? A progress note should be an accurate reflection of what occurred at the current visit. Although you were not present in the room with the patient and provider to know what happened, you can look for certain signs when reading chart notes. Examples include:

Established outpatient or subsequent hospital visit documentation that includes one or more of the following:

  • Long and detailed history of present illness (HPI)
  • Past medical, family, and social history (PFSH)
  • Allergies
  • Medication list
  • Comprehensive review of systems (ROS), either as a detailed table or “otherwise negative”
  • Conflicting information (i.e., “Patient reports SOB” in HPI, with “Resp: No SOB” in ROS.)
  • Same exam as previous visit(s), or same for every patient, every visit
  • Labs and/or radiology from weeks/months/years prior to visit
  • Same assessment and plan as previous visit(s)
  • Same amount of time documented as previous visit(s), or for every patient, every visit

Initial hospital visit (e.g., admits, history, and physicals (H&Ps), consults) documentation is or has:

  • Abnormally long, given the usual documentation habits of the provider
  • A comprehensive history documented for a patient that is well known to the provider
  • A comprehensive history and exam stated as having spent 10-20 minutes with the patient, given that over half was spent in counseling or coordination of care

Procedure documentation is or has:

  • The same documentation for every patient, every time it is performed
  • Conflicting information

Approach Providers Tactfully

Now that you have identified certain providers who show these signs, how do you approach them in a way that does not offend them? Try these seven tactics:

  1. Set up a time to meet with the provider in person. Talking with a provider about his or her documentation can be a touchy subject, and nonverbal cues are essential for avoiding confusion and misunderstandings.
  2. Be prepared with examples of the provider’s documentation illustrating your areas of concern. Have supporting guidelines on hand to show the provider.
  3. Offer positive feedback first. What does the provider do well? This sets an optimistic tone that will be the spoonful of sugar needed when you begin recommending changes.
  4. Ask questions before you request changes. Get all the facts first to confirm your assumptions about what you are seeing. Perhaps this provider does ask about social history at each visit because the patient’s medication requires the patient to abstain from alcohol. You shouldn’t assume it was not asked.

Here are some specific questions you may wish to ask the provider:

  • When you are seeing an established patient, do you discuss the patient’s PFSH at each visit?
  • I see that you have a detailed ROS table in all of your chart notes. Are each of the questions asked for each system or is it part of your template?
  • It looks like you always spend 25 minutes with each of your clinic patients. Is that an approximation of the time you spend? How do you count your time?
  • When one of your patients is admitted to the hospital, do you re-obtain the history that is documented?
  • I see you often bring the last five lab results into your notes. Are you discussing these results with the patient at the visit or do you bring them into the note for historical purposes?

5. Acknowledge, explain, suggest. Let the provider know you have listened. Explain why you are asking for a change to get his or her buy-in. Because most of us do not like to be told what to do, offer suggestions or recommendations rather than demanding a change. It is a gentler, more effective way to bring about compliance with your request. Suggestions to begin the conversation include:

  • “I hear what you are saying about wanting to have a complete snapshot of the patient’s history in your chart note so you only need to look back at your last visit for all the needed information. It is fine to bring all of that information into your note but, as a coder, I need to be able to identify what happened at today’s visit, so I can determine the appropriate level of service. What if you were to label the historical data as ‘Previously Obtained?’”
  • “When you are determining the amount of time you spend with your patients, you look at when your clinic started and ended and divide the time by the number of patients. In looking at your clinic schedule, I can see that you are very busy and I’m sure it is difficult to determine how much time you spend with each individual patient. In coding, we may only bill for the time you spend face-to-face with the patient. Knowing this, what do you think is the best way for you to count your time more accurately? Some providers I’ve talked with like to print a copy of their schedule so they can note enter and exit times on it. Would that work for you?”

6. Overcome objections. Listen very carefully to what the provider has told you. What is important to this provider? Timesaving documentation techniques? Billing at a higher level? Better patient care? Knowing your provider’s agenda is essential to dissolving his or her objections. Here are some questions and suggestions to keep the conversation moving in a positive direction:

  • “It sounds like adding ‘Previously Obtained’ to your notes each time would be too time-consuming to do for each patient visit. What if I were to create a template for you that already had everything labeled this way?”
  • “In listening to you talk about your patients, it sounds like you might be grossly underestimating the time you spend with some of them. Because you are basing your level of service on the time you document, you might be under-billing for some of the patients. It sounds like it would be worth an extra moment of your time to note your enter and exit time so you can be accurately paid for your time.”

7. Thank the provider for his or her time. Providers are very busy and it is important to honor his or her participation in the meeting.

EHRs are a great tool in improving documentation when used responsibly. Most providers want to document appropriately, but may not realize the pitfalls of certain documentation habits. Prior to EHRs, the old coder saying was, “If it wasn’t documented, it didn’t happen.” Now, we must ask, “It’s documented, but did it happen?”

Erin Andersen, CPC, CHC, has worked in coding and compliance since 2003 at Oregon Health & Science University performing chart audits and educating providers, coders, and staff about coding and billing. Ms. Andersen is the education officer in the Rose City chapter in Portland, Ore. and she is one of the Region 8 representatives on the AAPCCA Board of Directors.

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