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EHR Pitfalls: Keep Coders on Their Toes

Coders and physicians alike are finding electronic health records aren’t the magic bullet.

When electronic health records (EHRs) were first promoted, you may have been led to believe they could singlehandedly reduce medical errors, promote standardization of care, reduce costs, and increase physician efficiency. Physicians would be able to see as many, if not more, patients than they could pre-EHR and document all of it in an instant before ever leaving the exam room. No more chart stacks on desks at the end of each day; no more staying up late completing dictation or handwriting notes. That got physicians’ attention.
Now that EHRs are a reality, however, many physicians are finding they aren’t as magical at streamlining documentation as advertised. The issues associated with documentation in EHRs include:

  • There’s a learning curve to using the software.
  • Physicians must find lab results on patients somewhere in each electronic chart, rather than asking the nurse to call the lab to fax the results.
  • Physicians must navigate unfamiliar territory just to document the four simple letters “NKDA” (no known drug allergies).

But the biggest surprise comes after the documentation is done—the physician has to code it. Physicians were initially told the EHR system would automatically choose the codes at the press of a button.

Documentation Must Reflect Code Selection

With the roll-out of EHRs, you may have found yourself in the same situation as many coders. Consider, for instance, the following scenario:
In pre-EHR days, the physician could dictate diabetes mellitus (DM). The coder would look through the documentation to choose the type of diabetes mellitus and report the appropriate ICD-9-CM code.
If the physician documents DM in the EHR, by contrast, she is confronted with a list of ICD-9-CM codes from which to choose, including fourth and fifth digits to describe the type of diabetes mellitus. The patient may have hypoglycemia, as well, so the physician chooses what she believes is the perfect diagnosis: 250.82 Diabetes with other specified manifestations, type II or unspecified type, uncontrolled.
The physician may not realize, however, the importance of documentation matching the diagnosis code being billed. Unfortunately, what the documentation is missing for the service date is any mention of the DM being “uncontrolled,” or that the patient has hypoglycemia. Both of these conditions should be reflected in the note if ICD-9-CM code 250.82 is to be billed.

Physicians Decide Appropriate E/M Level

Another factor left up to physicians is choosing the appropriate evaluation and management (E/M) level in the EHR.
The EHR may give the physician E/M level suggestions based on the documentation for that service date. The physician still must know the basic elements required for each E/M visit level, as well as the requirements to bill a consultation or how to distinguish a new patient visit from an established patient visit.
Further questions arise in the exam portion of the E/M service. The parameters your EHR system follows determine if the physician has, for example, completed an expanded problem-focused exam versus a detailed exam. The difference can be the EHR suggesting your physician bill 99213 rather than 99214.
Another consideration is whether the EHR counts the medical decision making (MDM) level as one of the key components before choosing the E/M service level.
For instance, for an established patient office visit you are required to meet at least two out of three key components: history, exam, and MDM. Let’s say your physician uses an EHR template for a normal history and exam, which have enough elements to meet a 99214 (detailed history and detailed exam). The MDM was straightforward because it was a simple sore throat with no additional work-up and no prescribed drugs or tests.
Is your physician and practice comfortable with billing 99214 based on the detailed history and detailed exam, or are they more conservative and likely to lean toward a 99213 or 99212 based on the MDM’s content?
These are a couple of reasons why the physician should know the basic elements required for each E/M visit level prior to choosing and/or prior accepting the E/M level suggested by the EHR.

Use Timesaving Templates with Caution

Using a template or cutting and pasting portions of the three key components can be very timesaving for the physician; however, this should be done with great caution. You do not want a physician to use the same review of systems (ROS) or history on every patient they see. This could be construed as a “canned note,” and not specific to each individual patient’s distinctive problems. An indication of this occurring is when you see documentation like this:
CONST: No complaint of weight loss, fatigue, 
chills, or fever.
PULM: No complaints of cough, hemoptysis, wheeze, or SOB.
CV: No complaints of chest pain, angina, 
orthopnea, or PND.
FINAL DIAGNOSIS: Malaise and Fatigue.
This creates an EHR with conflicting information. The final diagnosis indicates the patient was seen for malaise and fatigue. The documentation, however, states the patient has no complaint of fatigue. It would appear the physician used her normal ROS template, but did not make any modifications to it.
The physician is permitted to use a template, or to cut and paste certain information, as long as the action was performed by the physician and the information is correct and specific to that patient’s visit on that service date. This means the physician always needs to proofread the template and modify certain elements to make it specific to each patient’s visit.

A Coder’s Role in EHR

Here’s where you, the coder, step in. Your coding knowledge is necessary to set up the EHR, to educate the physicians, to verify accurate documentation, and to maintain consistent coding. The EHR is a documentation tool, not a coding tool. A coder’s expertise is necessary to evaluate documentation clarity, consistency, and completeness. The coder will always be the mediator between the documentation and the bill that goes out the door, regardless of whether the documentation is handwritten, transcribed, or electronic.
A coder’s job isn’t finished when the bill goes out the door. Take into account all of the groups contracting with federal and state agencies to search for evidence of improper billing and overpayments. You have the alphabet soup of RACs, MACs, ZPICs, MICs, and most recently, HEAT. Physicians and facilities benefit by employing coders to review records requests and verify that the necessary documentation is present and supports what is being billed.
This is not to naysay EHRs. If you account for the learning curve and allow sufficient time for everyone involved to acclimate themselves to the new system, EHRs offer endless capabilities and wonderful reporting features. The important thing to remember is that EHRs aren’t magic. To deliver superior results, coding know-how and sound judgment is required.
Ronda Tews, CPC, CHC, CCP-P, is a corporate compliance project manager with St. John’s Health System in Springfield, Mo.

Evaluation and Management – CEMC

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