Orthopedic Coding Alert

Key: EHRs do not track physical examinations.

Among the many data tools available to your practice, useful electronic health records (EHRs) organize the medical and treatment history of a patient and monitor that patient’s recovery process. EHRs have the advantage over electronic medical records (EMRs) by providing cumulative information from specialists and creating a more holistic view of a patient’s health.

“While closely related, the terms EHR and EMR are not interchangeable. The EMR is the digital version of and individual practitioner’s or group practice’s patient chart,” says Heidi Stout, BA, CPC, COSC, PCS, CCS-P, with Coder on Call, Inc., in Milltown, New Jersey. “The EMR often cannot be transmitted from one practitioner to another, and these records must be printed to share health data. An EHR is designed for the secure sharing of information between all members of the care teams, like laboratories, primary care physician, specialists, facilities and the patient.”

The National Alliance for Health Information Technology restates the usefulness of EHR data by saying “[EHRs] can be created, managed, and consulted by authorized clinicians and staff across more than one healthcare organization.”

As you are coding, however, confusing situations can be created by EHRs. You might find yourself unclear about what documentation is necessary since EHRs cover so much of a patient’s history. You might also be unclear if the EHR’s code selection is accurate. Read on to find out how EHRs can coexist with your coding.

Learn What Documentation EHRs Cover

Are you relying too much on the information provided by EHRs that you find your coding documentation a little skimpy? You might find that EHRs cover most of the patient’s history anyway so it seems redundant to document everything a second time. However, there is one area that EHRs fail to cover.

A patient’s physical examinations are not carried over from visit to visit. This means that even if you record the examination, EHRs do not. You must provide documentation of a physical examination in every coding instance.

For example, if a patient complains about joint pain and stiffness on both sides of her body as well as loss of joint function, an orthopedist will perform a physical exam including probing of the sore joints, use code 86000 (Agglutinins, febrile [eg, Brucella, Francisella, Murine typhus, Q fever, Rocky Mountain spotted fever, scrub typhus], each antigen) to determine if the ailment rheumatoid arthritis. After the examination, the patient may be diagnosed with rheumatoid arthritis. You code M05.- (Rheumatoid arthritis with rheumatoid factor…). In your documentation, proof of examination must be included since the EHR will not provide those details if the patient must see a specialist in the future.

EHRs do provide some help for your documentation though. EHRs record past medical, family, and social history (PMFSH). According to the E/M guidelines, as long as a patient’s PMFSH has not changed since a prior visit, your provider can skip the documentation, saving time. It is imperative though that the provider documents that she has reviewed the PMFSH and assures it is up to date.

The takeaway is that although PMFSH does not need to be documented for coding, it does need a guarantee from the orthopedist that she reviewed the documentation and can claim it is up to date. This substitute, however, does not exist for physical examinations and therefore these must be well documented if your code is going to be accepted.

Listening to the Suggested Code Might Be a Mistake

EHRs offer E/M code suggestions based on the information it has in its system. This can be helpful for new coders wanting a second opinion to confirm their coding choices, but should you rely on this function?

“No,” says Denise Paige, CPC, COSC with PIH Health in Whittier, California. “Most coders turn that option off.”

In the CMS Carriers Manual, it is stated that the primary requirement for proper reimbursement is medical necessity. This corresponds with what the 1995 E/M guidelines outline as the essential factors of reimbursement, which are reason for the encounter and relevant history, physical examination findings and prior diagnostic test results.

This means that the EHR, which compiles the entire PMFSH, may base its suggested code on irrelevant information. For example, in the earlier case, your patient is complaining of swelled joints. In the patient’s PMFSH that the EHR has access to, it might see that the patient has peanut allergies, which might account for the swelling. It may suggest an allergy code like T78.01 (Anaphylactic reaction due to peanuts…) in addition to the arthritis code.

Sometimes the EHR code may not necessarily be wrong, but you may fall into the common pitfall of over coding. Avoid this by taking matters into your own hands to review the information and code for yourself. The EHR can provide a decent suggestion, but the ultimate decision falls on you and the clinician.