Wiki Would like auditor's opinion on EHR/claim disparities

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HangarPilot

HangarPilot

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I have a question I'd appreciate an auditor's take on...

When we create claims through our EHR (eClinicalWorks), the claim is a "snapshot in time" ... it pulls the coding from the chart and generates the claim. When there's an issue and the coding needs to be changed, it's easy enough to correct the claim and submit/resubmit. However this only corrects the claim -- the "chart" still contains the original coding. Because of this, we go the extra step to correct the coding in the Progress Note as well. I'm told this is because of concerns that an auditor would see a discrepancy between the chart and the claim. My concern is that we may be doing extra work that's not necessary.

Sometimes this happens prior to claims going out - it could be something simple like dx codes sequenced incorrectly. Or maybe a code was left off like 90460 for vaccine counseling. An extreme example might be that the provider used an established patient code and they are a new patient (or vice-versa).

Sometimes this occurs when a claim is denied. We have just one HMO that wants infant Well Visits to use codes Z00.110 and Z00.111 ... all others want Z00.129 ... so this gets missed on occasion. In this case, it's been a week or more so the charts are locked. We can correct and resubmit the claim easily but we have to have the provider unlock the chart and change to the dx in the Progress Note. I hate bothering providers for this and I feel this is only an EHR quirk ... if we had paper charts and a SuperBill you wouldn't go back to the provider and say "I need to line out this code and draw a circle around this one" would you? The chart has a proper Well Visit dx ... just not the one this carrier wants to see.

Of course this is an EHR so there are logs to provide an audit trail to show who changed what. Wouldn't that be sufficient to explain any disparity?

My question is... Is this extra work necessary and/or prudent? Opinion please - prudence or paranoia? :)
 
it really does not matter if the code number on the claim matches the code number that the provider puts in the chart note. Codes should be based on the narrative rendered diagnosis and services in the providers own words in the chart note. so as long the information on the claim is supported by the narrative note, then there is no reason to change the code numbers entered thru the system in the notes.
 
My position is that the claim's coding needs to accurately reflect the physician's documentation and as long as it does, it does not matter if there is 'coding' in the chart that does not match the claim - there should be no need to have the provider edit the chart to change the codes as long as the narrative documentation itself is correct. I've discussed this with professional auditors as well and they agreed - I've been told auditors will validate the submitted claims against the documentation and will generally ignore any 'coding' that happens to be in the chart as internal information only since it is not reported to any payers.
 
I'm not familiar with the EHR you use. The EHRs I've used provide various templates, documents, modules and so on. In each practice I've worked with we have defined the legal medical record as only the documents that are produced after all of the information is entered into the various templates.

Then I request that the final diagnosis codes are removed from the documentation. The physician's final assessment is still listed, but that is easier for them to review and correct a word or two if they have chosen wrong within the EHR software. While a background template may show the incorrect procedure/diagnosis, the document shows the actual information. It allows for the codes to be changed easier with less physician intervention. The templates are not pulled by auditors and I've certainly never sent them.

I do require addendums/corrections at a later date if it is drastic, for example if the assessment states something like Asthma, but it was really Actinic Keratosis. That is rather extreme, but you get the point.
 
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