Watch Out for Misused EHR Documentation Shortcuts

Knowing the risks EHRs pose is the first step to improving E/M documentation.

By Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC
The use of electronic health records (EHRs) is steadily increasing, and so are the number of high-level evaluation and management (E/M) services being billed. These claims may very well be substantiated by documentation contained in the EHR, but is the documentation valid? That’s what government and private payers are questioning, and that’s what practices have to prove if audited.

The Best EHRs Are Also the Worst EHRs

The crux of the problem is that the same time-saving features that attract physicians to use EHRs, such as copying and pasting or pulling forward documentation and templates, can also put practices at risk for failing an audit. Used inappropriately, these features can create “cloned” documentation (e.g., the documentation is the same from visit to visit, or from patient to patient) or other errors in the EHR that are easily detected by an auditor. The key is to be ever vigilant, scrutinizing your physicians’ documentation from the perspective of an auditor.

Confirm the Chief Complaint and HPI

The way audits are conducted varies. Sometimes, an auditor may have access to the EHR. Other times, the records are printed and sent to the auditor. In either circumstance, the system compiles all of the information entered during a visit into a neat progress note format. This is typically how the auditor will view the information.
The first thing an auditor looks for is a documented chief complaint. Documentation guidelines require the chief complaint to establish medical necessity. They also require the chief complaint to be documented by the physician; however, some payers will allow documentation from the medical assistant (MA) or nurse. Most EHRs provide a field to enter a chief complaint or the reason for the visit, but it can be inferred from the history of present illness (HPI).

Check if the Physician Entered the HPI

HPI may be entered through a list of drop down menus, via point and click options, or using “free text.” Documentation guidelines explain that recording the HPI is physician’s work; auditors need to ensure the physician documents this portion of the record. This poses a huge challenge for auditors because there may be no indication in the EHR when someone other than the physician completed the HPI.
For example, I performed an audit for an office wanting additional education. In shadowing the providers, I learned that the Medical Assistant was fully documenting the HPI for every patient. I quickly informed the physicians that they should be doing this work. Had I not been there in person, however, I would not have known this, and I would have mistakenly given credit to the physicians for completing the HPI.
Payers are catching on to this issue. EHRs often have an internal log that tracks who is entering what within the record. Payers are beginning to ask for audit trail logs to see who documented the HPI. As an internal auditor for a practice, you should ask for this, as well. If you cannot get the log, look for clues within the documentation. Paper charts were easy to track because the handwriting was different. Clues are more subtle in the EHR. For example, documentation may state, “You told her to take her meds twice a day,” or “Dr. XYZ told the patient to take Tylenol.” Phrases like this raise the question, “Who documented that HPI?” HPI should not be counted toward the level of E/M service when there is valid reason to believe someone else documented it.

ROS and PFSH Must Be Updated at Each Visit

The review of systems (ROS) and past, family, and social history (PFSH) may be documented by ancillary staff, gathered from a form completed by the patient, or updated from an earlier visit. The visit documentation should note the source of this information.
If the ROS and PFSH are gathered from a form, the physician needs to document that he or she reviewed the form, and sign and date it. The form also should be scanned into the EHR. If the ROS and PFSH are copied and pasted, or pulled forward from an earlier visit, the note should indicate the original date of service and confirm that the ROS and PFSH were reviewed and updated at the current visit.
Many EHRs automatically populate PFSH information from other areas into the visit note documentation, without a clear indication that the physician reviewed the information during the visit. If there is a concern that PFSH was pulled into the visit documentation automatically, the auditor must verify who accessed the information and when it was accessed using audit trail logs.

When Using Templates, Verify the Exam

The issues with templates also carry over into exam elements. EHRs often have exam templates geared to a specific complaint or that are pre-populated with findings. The physician scrolls through the template, pointing and clicking on items to select as positive or negative.
Some systems are able to carry forward or copy and paste a previous exam. This can be a time-saver for patients who are seen at regular intervals for chronic condition follow up. But templates may also result in documentation errors if exam items are pulled forward that aren’t actually performed, or if the physician doesn’t change a result that may have been positive at a previous visit, but is negative for the current visit.
Example 1
When a patient presents for diabetes (DM) follow up (F/U), a DM F/U template is used. The template is pre-populated with ROS negatives, exam negatives, etc. It’s up to the physician to change any of the findings to positives. It’s also up to the physician to remove elements that he or she didn’t examine. If the physician fails to do these things, the template will create nearly identical notes, and create flawed documentation.
Example 2
I worked with an OB/GYN office that created a template for their GYN exams. The template pre-populated all the exam elements as negative. Numerous times during their audits, I would find exam elements that indicated a negative finding when the HPI or the ROS would indicate the opposite. This makes the validity of the documentation questionable and renders the level of service unsupported. Credit cannot be given for elements where discrepancies occur.

Don’t Overlook Dx Selection

EHRs can make documenting the assessment and plan of an E/M service easier by providing diagnosis codes and including check boxes for the status of problems (improved, worsening, etc.), and by linking the plans to each diagnosis. Some systems provide a “favorites list” that keeps the diagnoses the physician uses most right at his or her fingertips.
These tools — helpful as they may be — can also result in incorrect documentation. Auditors must look out for assessments populated from problem lists. The history and exam must support each diagnosis, showing that it truly was assessed at that particular visit. Often, the level of service is coded higher because chronic conditions are pulled into the assessment from a problem list, but there is no evidence in the history or exam that the condition was addressed during the visit, or that it affected the patient’s treatment.
Integrated diagnosis codes also can create problems if physicians do not take the time to find the most specific code.
Example 3
The patient has diabetes, type II, uncontrolled, with renal complications. The physician types in “diabetes,” and so many codes come up that he or she just picks the first on the list: diabetes, type II, controlled, without complications. Or the physician pulls a diagnosis for DM, type II, uncontrolled, but the documentation does not support the uncontrolled designation.
Favorites lists can really cause havoc if physicians are able to rename the diagnosis associated with a given code. For instance, I once audited a physician who had saved the code for an abnormal Pap smear into her favorites list, shortening and renaming it “pap.” She then mistakenly used this code for any patient who came in for a routine Pap smear.
When scoring out the medical decision-making (MDM), you must verify the selected codes are supported in documentation and that each scored item was truly addressed at the visit. Using an EHR can often result in a physician not providing a detailed enough plan to support the level of MDM. The physician’s thought process — used to complete the picture of that visit and to ensure an accurate selection of MDM — gets lost in the mix.

Customize EHRs to Overcome Shortcomings

Internal audits are tremendously important to any organization’s compliance processes. Through the audit process, you can uncover and address documentation concerns with EHRs. Customize your EHR to:

  • Assist physicians in the documentation process so they have more time to provide quality care to patients;
  • Reduce compliance risk to your physicians and your organizations; and
  • Ensure documentation guidelines are met and that services billed are supported.

Whether you are shopping for an EHR or looking to restructure the way your existing EHR works, look at areas of concern uncovered in internal audits and ask your vender to add features to correct these areas (for example, adding a feature to display who documented the HPI and exam). Ask the vender if they can add dates from which a previous ROS was pulled forward, etc. Be sure you choose an EHR that is customizable to meet your organization’s needs and don’t hesitate to put that vendor to work to ensure you get the system that works best for your organization.
A final note: Ensure your physicians and staff are thoroughly trained on the EHR by individuals who are knowledgeable in clinical and billing guidelines.
Ellen Risotti-Hinkle, CPC, CPC-I, CPMA, CEMC, CFPC, CIMC, is an AAPC national ICD-10 trainer, an online adjunct instructor for Ultimate Medical Academy, and president and CEO of Rizhink Medical Consulting, LLC. She is a member of the Indianapolis, Ind., local chapter.

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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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