Devise a Plan to Improve E/M Error Rates in EHRs

Devise a Plan to Improve E/M Error Rates in EHRs

New prepayment audits underscore the importance of proper EHR use.

If your practice, clinic, or hospital uses an electronic health record (EHR) but does not have a current “copy and paste” policy, it’s time to create one. To understand why this is important, let’s consider long-standing evaluation and management (E/M) coding challenges, how payers are reacting to high E/M coding error rates, and why poor documentation practices in the EHR can exacerbate those problems.

E/M Error Rates Historically Have Been High

The Office of Inspector General (OIG) recently released a report titled “Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010.” CMS referenced this study in the June 29, 2017 MedLearn Matters® (MLN) report:

In a study report, the Office of the Inspector General (OIG) noted that 42 percent of claims for Evaluation and Management (E/M) services in 2010 were incorrectly coded, which included both upcoding and downcoding (i.e., billing at levels higher and lower than warranted, respectively), and 19 percent were lacking documentation. Several physicians increased their billing of higher level, more complex and expensive E/M codes. Many providers submitted claims coded at a higher or lower level than the medical record documentation supports.

OIG found that Medicare inappropriately paid $6.7 billion (in 2010 dollars) for claims with E/M services coded incorrectly, lacking appropriate documentation to support the code assigned, or both. This represented 21 percent of Medicare payments for E/M services in 2010.

In a separate 2014 statement the OIG noted, “The Centers for Medicare & Medicaid Services (CMS) found that E/M services are 50 percent more likely to be paid for in error than other Part B services; most improper payments result from errors in coding and from insufficient documentation.”

2017 Update: MACs Begin
Prepayment E/M Audits

Because of its findings, the OIG recommended in 2014, “CMS educate physicians on coding and documentation requirements for E/M services, continue to encourage contractors to review E/M services billed for high-coding physicians and follow up on claims for E/M services paid in error.” Now, CMS contractors are cracking down on E/M services, and have begun to issue prepayment reviews for certain services with high error rates. For example:

The top services for First Coast Service Options Inc. (First Coast – CMS MAC) with payment errors identified by Part B comprehensive error rate testing (CERT) continue to be evaluation and management services. First Coast recently conducted data analysis due to the high CERT error rates for evaluation and management services pertaining to Current Procedural Terminology (CPT®) code 99223 (initial hospital care). The majority of the CERT errors were for services that were recoded to a lower level of care or to a subsequent hospital care visit. In response to the high percentage of error rates and continual risks of improper payments associated with initial hospital care visits, First Coast will implement a prepayment threshold audit for CPT® code 99223 claims submitted on or after July 25, 2017, and this audit will apply to all provider specialties (with the exception of claims for 99223 for provider specialties 06-Cardiology and 11-Internal Medicine, as there is currently a separate prepayment threshold audit in place for these provider specialties). The new audit will be based on a predetermined percentage of claims in an effort to reduce the error rates for these hospital services.

No provider wants to experience prepayment audits because claims are not paid until they are reviewed. The auditor reviews X number of claims and extrapolates an error rate to your entire universe of claims. This is costly to providers if faced with take-backs from CMS for E/M overpayments.

EHRs Can Exacerbate E/M
Documentation Shortcomings

Many EHRs allow users to copy and paste data from one entry to another, which can lead to clinical mistakes, over coding, and improper reimbursement.

Clinicians are becoming more vocal in their distrust of the copy and paste function in the EHRs. An article by Joseph M. Pierre, MD, in the July 7, 2017 edition of Medscape Nurses relates copied and pasted data to “fake news.” According to Pierre :

Take, for example, a young man who was hospitalized with “posttraumatic stress disorder” related to an “injury from a rocket launcher” in military combat overseas. Although that history was charted over and over again through copy and paste, when I sat the patient down to discuss the details, it turned out he’d merely sustained a rotator cuff injury after throwing a grenade during a basic training exercise stateside. No rocket launchers, much less PTSD, to speak of.

Pierre suggests copying and pasting key components of the E/M including history, review of systems (ROS), and in some instances the physical examination is problematic and represents a digital version of the “telephone game,” with “information that was initially misinterpreted or misdocumented subsequently set in stone by perpetual duplication. That kind of misinformation fuels inaccurate diagnoses and can lead to inappropriate and unnecessary treatment.”

The OIG is aware of the issues with electronic E/M documentation and now classifies it as healthcare fraud. In 2013, OIG Inspector General Daniel Levinson suggested that CMS, “work with ONC and hospitals to develop guidelines for using the copy-paste feature in EHR technology. Specifically, CMS should consider whether the risks of some copy-paste practices outweigh their benefits. For example, CMS could provide guidance to hospitals on copy-pasting identical text in records of multiple patients.”

Devising a Cut-and-Paste Policy

In 2014, OIG submitted an electronic questionnaire and interviewed staff at 864 hospitals. They found only a quarter had policies regarding the use of copy and paste functions in their EHRs.

What does a good copy-and-paste policy look like? 

The act of copying and pasting data is not always bad, but the data must be reviewed for accuracy and that accuracy needs to be acknowledged via signoff by the clinician importing the data and providing care. The policy should include the stipulation that a provider must review the imported data, make necessary corrections, and add their signature attesting that they reviewed the imported data and found it to be correct (or made necessary modifications). This should be done for the history, ROS, exam, and treatment plan (i.e., any area that is imported). The policy should also stipulate the chief complaint must be compared to the treatment plan and all issues must be addressed. Documenting the physician “work” supports the provision of the key components of the E/M service.

Many EHRs have macros that generate significant documentation with a single click — basically, charting by exception. When faced with imported data in an EHR (which is more often than not), focus on the place of service, chief complaint (CC), exam, and medical decision-making (MDM).

Any record that indicates a “normal” exam that is not in accord with the CC or the diagnosis raises a red flag. Look closely at the MDM; when none is documented, or it does not reflect the CC or address abnormal exam findings, consider returning the record to the provider for query.

A lack of MDM appropriate to the DOS may indicate the entire record was cloned and should not be coded. The old adage “if it’s not documented, it didn’t happen” applies to electronic records, as well. More importantly, the documentation in the EHR must match the patient’s current condition.

I predict the E/M guidelines will be revisited to reflect our digital world. Until then, be careful with cut-and-paste documentation in EHRs, as the 1995 and 1997 Documentation Guidelines for Evaluation and Management Services still apply.

Why Are E/M Error Rates So High?

The same evaluation and management (E/M) documentation guidelines have been with us for over 20 years, but E/M coding continues to be a challenge. Why are error rates so high, despite the consistency of the guidelines? Here are some possibilities:

E/M assignment is supposed to be objective, but providers assigning their own codes may overestimate the value of their time. This can result in over or under coding.

Reimbursement values have fallen for providers over the years. To maintain income and revenue, providers may over code E/M services.

Clinicians are not necessarily great coders. Coders are more familiar with guidelines, and less likely to over or under code.

Untrained or inexperienced coders are more prone to errors. This is not germane only to coding. Training is essential and should be an ongoing activity.

Some coders become experienced in “reading between the lines.” They become familiar with the provider’s documentation habits and will erroneously code something not clearly documented because they know it was likely done and what the provider was “thinking.”

Some providers use billing services that promise increased returns for the same work. This likely means services are upcoded. Provider signatures accompany claims from billing companies, which makes them responsible for the actions of that entity.

“We’ve always been paid before” is akin to “we’ve always done it that way.” This results in the Medicare administrative contractors reviewing Comprehensive Error Rate Testing reports and finding that, yes, you have always done it that way, but it’s always been wrong (which results in a prepayment audit).

Resources

OIG, Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010: https://oig.hhs.gov/oei/reports/oei-04-10-00181.asp

MLN Connects, June 29, 2017, Provider Compliance, Evaluation and Management: Correct Coding: www.cms.gov/Outreach-and-Education/Outreach/FFSProvPartProg/Provider-Partnership-Email-Archive-Items/2017-06-29-eNews.html#_Toc486414847

OIG, Coding Trends of Medicare Evaluation and Management Services: https://oig.hhs.gov/oei/reports/oei-04-10-00180.pdf

CMS, 1995 and 1997 Documentation Guidelines for Evaluation and Management Services:

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/95Docguidelines.pdf

www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNEdWebGuide/Downloads/97Docguidelines.pdf

CPB : Online Medical Billing Course


 Barbara Aubry, RN, CPC, CPMA, CHCQM, FABQAURP, AAPC Fellow, is a senior regulatory analyst for 3M Health Information Systems. As a member of the 3M HIS team that creates and manages medical necessity and other coding data, she works directly with the ICD-10 code translation and assignment for National Converge Determination medical necessity policies. Aubry’s clinical background includes experience in hospital case management and utilization review, and her core focus is regulatory compliance and auditing. She is member of the Upper Saddle River, N.J., local chapter.

2 Responses to “Devise a Plan to Improve E/M Error Rates in EHRs”

  1. Michael Warner, DO, CPC, CPMA says:

    Dear Barbara,
    Excellent article! As a physician, I can tell you that most medical records are populated with template/copy-forward information. When audited, these charts provide all of the necessary bullets to award an appropriate level of service, but the information is factitious. The records tell a story, but not the patient’s story.
    I invite you to consider another option: let the patient complete the History and co-author the History component of the medical record. And, encourage the patient to read/review the medical record after the visit to assure for accuracy and to allow the patient to better understand the assessment and treatment plan.
    Last February, I published a clinical research paper “Use of Patient-Authored PreHistory to Improve Patient Experiences and Accommodate Federal Law” in JAOA. We accepted a patient’s PreHx as a written request to amend the health record per the HIPAA Privacy Rule [45 C.F.R. § 164.526]. Rather than take 60 days to decide whether to accept the amendment, per our research protocol, we accepted the amendment immediately. This gave us the ability to populate the History with the patient’s written words as documented in the PreHx.
    As the doctor who accepted the PreHx’s in the study, the transfer of data was a game changer. I walked into the room, greeted the patient, and then spent less than a minute reviewing the patient’s concerns in the electronic health record (EHR). From there, I was able to review what I learned by asking the patient, “You are telling me that this and this are going on?” This led to a few more specific questions, then a pertinent examination. Because the patient and the provider where both highly engaged, medical decision making transformed into shared decision making.
    Because of the efficiency of data gathering during our 15-minute office schedule, all charts were completed at the end of the face-to-face encounter. At the checkout window after the visit, each patient was given a copy of the medical record encounter note. They were instructed to go home, read their health record, and score their experience with an anonymous survey.
    Patients responded feeling highly satisfied with their experience as a patient in our office (97%). They believed that completing a PreHx made them feel more empowered in their health care. They also appreciated being given a chance to co-author their medical records. Best of all, patients reported feeling better and understood by having submitted a PreHx.
    In our clinical research project, we sent a standard envelop to patients one-week in advance of a scheduled office visit with the family doctor. The envelop included an invitation to participate in research with Internal Review Committee approval along with a PreHx and two sample PreHx’s. 64% pf patients participated, completed a PreHx, and co-authored their medical record. Ages ranged from 14 to 94 with statistically equal participation from all age groups. Of interest, 60% of respondents were male.
    Consumer commerce once had a problem with purchase transactions. A customer could be billed for items and have trouble viewing the receipt or disputing a false charge. The Fair Credit Reporting Act of 1974 gave consumer the right to see receipts and dispute charges. When you go to a store, like Walmart, you are not only given a receipt, but are also shown a register tally screen while items are scanned. If there are two beeps when one can of mayonnaise is scanned, you are able to say, “Did that register twice?” The cashier can immediately review the items and the digital tally and make the correction. This type of consumer responsibility along with engagement with the cashier helps eliminate incorrect charges. This keeps transaction data accurate, which has far-reaching effects beyond the consumer transaction to warehouse supply to product demand.
    From a policy standpoint, it will be difficult for our government to regulate the use of EHR cut & paste and copy forward functions. With active patients who read their health records and contribute/co-author, however, the problems of EHR errors and inaccurate records should evaporate.
    During our study, we used a 2 ½ page printed PreHx. This required patients to print the form and complete it with handwriting. We recently launched a digital PreHx. This allows the patient to complete a PreHx which is then emailed to the patient in its final form. This document can be printed or forwarded to a medical provider as a request to amend the medical record.
    Thank you for your detailed article. Hopefully, you will enjoy this message of patient participation to improve medical documentation.
    Sincerely,
    Michael

    Michael J. Warner, DO, CPC, CPMA
    President, Patient Advocacy Initiatives
    2017 AACOM Health Policy Fellow
    All PreHx forms – paper and digital – are available for free at http://www.PatientAdvocacyInitiatives.org
    Let’s connect at http://www.linkedin.com/in/michael-warner-24a82539

  2. Michael Warner, DO, CPC, CPMA says:

    Dear Barbara,
    Excellent article! As a physician, I can tell you that most medical records are populated with template/copy-forward information. When audited, these charts provide all of the necessary bullets to award an appropriate level of service, but the information is factitious. The records tell a story, but not the patient’s story.
    I invite you to consider another option: let the patient complete the History and co-author the History component of the medical record. And, encourage the patient to read/review the medical record after the visit to assure for accuracy and to allow the patient to better understand the assessment and treatment plan.
    Last February, I published a clinical research paper “Use of Patient-Authored PreHistory to Improve Patient Experiences and Accommodate Federal Law” in JAOA. We accepted a patient’s PreHx as a written request to amend the health record per the HIPAA Privacy Rule [45 C.F.R. § 164.526]. Rather than take 60 days to decide whether to accept the amendment, per our research protocol, we accepted the amendment immediately. This gave us the ability to populate the History with the patient’s written words as documented in the PreHx.
    As the doctor who accepted the PreHx’s in the study, the transfer of data was a game changer. I walked into the room, greeted the patient, and then spent less than a minute reviewing the patient’s concerns in the electronic health record (EHR). From there, I was able to review what I learned by asking the patient, “You are telling me that this and this are going on?” This led to a few more specific questions, then a pertinent examination. Because the patient and the provider where both highly engaged, medical decision making transformed into shared decision making.
    Because of the efficiency of data gathering during our 15-minute office schedule, all charts were completed at the end of the face-to-face encounter. At the checkout window after the visit, each patient was given a copy of the medical record encounter note. They were instructed to go home, read their health record, and score their experience with an anonymous survey.
    Patients responded feeling highly satisfied with their experience as a patient in our office (97%). They believed that completing a PreHx made them feel more empowered in their health care. They also appreciated being given a chance to co-author their medical records. Best of all, patients reported feeling better and understood by having submitted a PreHx.
    In our clinical research project, we sent a standard envelop to patients one-week in advance of a scheduled office visit with the family doctor. The envelop included an invitation to participate in research with Internal Review Committee approval along with a PreHx and two sample PreHx’s. 64% pf patients participated, completed a PreHx, and co-authored their medical record. Ages ranged from 14 to 94 with statistically equal participation from all age groups. Of interest, 60% of respondents were men.
    Consumer commerce once had a problem with purchase transactions. A customer could be billed for items and have trouble viewing the receipt or disputing a false charge. The Fair Credit Reporting Act of 1974 gave consumer the right to see receipts and dispute charges. When you go to a store, like Walmart, you are not only given a receipt, but are also shown a register tally screen while items are scanned. If there are two beeps when one can of mayonnaise is scanned, you are able to say, “Did that register twice?” The cashier can immediately review the items and the digital tally and make the correction. This type of consumer responsibility along with engagement with the cashier helps eliminate incorrect charges. This keeps transaction data accurate with far reaching effects beyond the consumers acquisition of goods to warehouse supply and product demand.
    From a policy standpoint, it will be difficult for our government to regulate the use of EHR cut & paste and copy forward functions. With active patients who read their health records and contribute/co-author, however, the problems of EHR errors and inaccurate records should evaporate.
    During our study, we used a 2 ½ page printed PreHx. This required patients to print the form and complete it with handwriting. We recently launched a digital PreHx. This allows the patient to complete a PreHx which is then emailed to the patient in its final form. This document can be printed or forwarded to a medical provider as a request to amend the medical record.
    Thank you for your detailed article. Hopefully, you will enjoy this message of patient participation to improve medical documentation.
    Sincerely,
    Michael

    Michael J. Warner, DO, CPC, CPMA
    President, Patient Advocacy Iniatives
    All PreHx forms – paper and digital – are available
    for free at PatientAdvocacyInitiatives.org
    Let’s connect at http://www.linkedin.com/in/michael-warner-24a82539

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