Conquer E/M Challenges of EHRs
Arm against fraud risks EHRs pose, and develop policies to reinforce compliance.
Electronic health records (EHRs) make documentation more legible, but they also make it easier to inflate content. Evaluation and management (E/M) documentation is especially prone to EHR shortcomings because of the repetitive nature of these services. Let’s consider the risks and resolutions.
Some EHRs do not identify true authorship of the documentation. For example, a note may print with the provider’s authenticating signature, but the audit function within the EHR reveals that the medical assistant measured and documented the vital signs and past, family, and social history (PFSH).
Below is an example of the resident’s and teaching physician’s signatures at the bottom of the document, with the physician’s attestation above the resident’s signature. Looking at the printed encounter note, it’s unclear what the resident performed versus the teaching physician.
This patient was discussed with the resident and I agree with the resident’s findings and plan as documented in the resident’s note.
Electronically signed by John Resident MD on XX/XX/XXXX at 10:00 a.m.
Electronically signed by Jane Doctor MD on XX/XX/XXXX at 10:20 a.m.
There should be a separate physician note following the resident’s signature.
Watch for Cloning
The Centers for Medicare & Medicaid Services (CMS) defines cloning as, “copying and pasting previously recorded information from a prior note into a new note.” Certain features, such as auto-fill and auto-prompts, “can facilitate and improve provider documentation, but they can also be misused. Simply changing the date on the EHR without reflecting what occurred during the actual visit is not acceptable.”
Copy and Paste and Copy Forward functions in EHRs make it easy to inflate documentation to support a higher level of E/M service than is warranted. Documentation must support medical necessity for a particular level of service. CMS stresses in the Medicare Claims Processing Manual, Chapter 12 – Physicians/Nonphysician Practitioners (30.6.1):
Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. 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.
When copying information, the provider might include irrelevant details such as conditions that have been resolved, conditions not treated at the visit, or conditions treated by other providers that do not affect the visit. Documentation that represents more work than was performed is fraudulent.
For instance, some EHRs “gray out” information copied forward. If the entire note grays out, the provider is requesting reimbursement for a visit that happened perhaps a week ago, a month ago, or last year — anytime other than today. Following is an example (of an excerpt to show inconsistencies) that was pulled forward, in which only the assessment was updated.
Chief complaint: Patient presents for nine-week prenatal checkup.
Exam: Gravid uterus 7-9 weeks size. FHT is not audible.
Assessment: Gestational age 38 weeks.
Don’t Fall for Template Traps
Pre-populated templates are a timesaver, but can be problematic. Here are two unfavorable scenarios that can occur during E/M visits:
An auditor reviews documentation and the review of systems (ROS) contradicts the history of present illness (HPI) because the provider pulled in the ROS template and did not change the negatives to positives based on the visit. An auditor may determine the provider gets zero credit for the ROS because she cannot know what information is accurate, due to the inconsistencies.
The medical history template states the patient has no significant medical history, but the patient presents with three chronic conditions, is on three different medications, and has had several surgeries.
Auto-populated templates are not always gender-specific. For example, a primary care physician pulls in the exam template, but does not make changes because the patient had a normal exam. In this case, the gender of the patient is female, but the exam specifies, “Prostate: normal size prostate without nodules.”
There are also templates for time. For example, the template may state that for every established patient visit, the physician spent 25 minutes with the patient face-to-face, with greater than 50 percent of the time spent counseling on diet and exercise. It is not possible that every established patient, no matter the age, medical history, or presenting illness, requires exactly 25 minutes of face-to-face time.
Look Out for Information Overload
Medicare administrative contractor Palmetto GBA defines over-documentation as:
… the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services. Some EHR technologies auto-populate fields when using templates built into the system. Other systems generate extensive documentation on the basis of a single click of a checkbox, which if not appropriately edited by the provider may be inaccurate. Such features produce information suggesting the practitioner performed more comprehensive services than were actually rendered.
A 20-page encounter note containing HPI documentation for every time the patient came to the clinic could cause a duplication of service, a delay in receiving necessary care, poor communication between the providers, patient care errors, and/or improper payment if an auditor gives credit for the past history.
Typically, over documentation results from using EHRs in ways we’ve already mentioned, such as cloning and auto-populated templates.
Don’t Count on EHRs to Code Diagnoses
EHRs can import diagnosis codes and descriptors, but if an impression reads “diabetes mellitus type II with hyperglycemia,” for instance, and the documentation does not contain lab values, the coder cannot defend E11.65 Type 2 diabetes mellitus with hyperglycemia as the correct code choice. Based on the content of the encounter note, diabetes type II without manifestation is more accurate. The difference in coding diabetes unspecified versus diabetes with a manifestation affects risk coding for hierarchical conditions.
Although coding to the highest level of specificity is preferred, the documentation must support the higher specified code.
Impact on Coders, Providers, and Patients
Documentation cloning makes it difficult for coders to tell which information applies to the current encounter. For instance, documentation of a history and exam without relevance to the patient’s age and health history makes it difficult to determine which components are medically necessary. It may not be clear if the diagnosis is stable/improving or unstable/not improving. This could cause a change in the level of medical decision-making when determining the correct level of service.
Because some systems allow the user to copy all or part of a note forward from one visit to the next and from one patient to another patient, the risks are high: Patients can have diagnosis errors, treatment errors, incorrect ordering of test, medications prescribed that they are allergic to, etc. Providers can forget to remove information that’s no longer applicable. The HPI and impression may contradict between a condition being current and resolved. Inflation of documentation can cause overpayment of services.
EHRs have also taken away individuality and provider opinion. Smart phrases and check boxes have categorized information in the document, causing the notes to sound the same. Gone is the provider’s opinion.
Solutions for Smart EHR Use
Compliance professionals must understand the EHR they oversee. If your facility/practice has multiple EHRs, know them all. Know how the providers create their note. Sit in on their training. Chances are, someone with information technology knowledge (rather than compliance knowledge) is training the providers. They are teaching what the system is capable of, as opposed to how best to use the system for positive clinical, compliance, and coding outcomes.
Know where each piece of information is housed in the EHR system. If audited, does the release of information (ROI) department know what information should be sent for the date of service in question? For example, when auditing a provider’s note, who stated the PFSH was documented under a different tab, my response was:
You must reference the location of the PFSH.
If this note were audited and your ROI department sent the encounter note, would they also send the information from the PFSH section?
If they did send the information, will your authentication be on it with the date showing when you reviewed it?
If the patient was seen since then, is the most current review date now overriding the date from the date of service in question?
If your practice is upgrading or changing the EHR, ask to be involved from the beginning. You’re the best person to advise on a compliant system or training program. When involved, you’re in a better position to advise administration of the risks early in the decision-making process, rather than after the system has been purchased and/or customized for your healthcare organization.
There are several questions you should ask about the copy and paste function in your EHR:
- Does the risk outweigh the benefit?
- Does the information misrepresent the service provided at the encounter?
- Can this function be controlled?
- Does your system allow you to turn off the function for copying information forward?
- Does your system allow for customization allowing duplication of specific sections, only?
As an organization, you might decide it’s best to disable or restrict the Copy and Paste functions. If the decision is made to allow copying of information, put in place an audit process to make sure your providers are not putting themselves and the practice at risk. It’s hard to change habits, so it’s imperative to stay ahead of the game.
Be sure your providers are removing fields in the template that aren’t used. If a section is non-applicable to the patient, don’t just leave the field blank. Remove it. For example, a male patient — or female patient who has been in menopause for 20 years — should not have a blank field for last menstrual period.
Do all employees have the proper access? Does the receptionist have the capability to addend an encounter note to communicate a phone call from the patient to the physician? Most systems have a separate place for documenting phone messages and communications. Allowing non-clinical employees to make addendums to a legal medical document is not a proper use of the system.
EHRs, when designed well and used properly, are beneficial. The EHR is not the enemy. It’s a tool created to help with efficient healthcare documentation. After you identify the risks inherent in your EHR, develop policies to reduce those risks. When inconsistencies arise, educate your providers. Remember: Communication is key to success.
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