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6/13/2013
1
Documentation Concerns With EMR
Presented by:
Melody S Irvine Melody S. Irvine, CPC, CPMA, CEMC, CPC‐I, CFPC, CCS‐P, CMRS
Property of Career Coders, LLC. All rights reserved. These materials may not be duplicated without the express written
permission of Career Coders, LLC -© 2013
This presentation is for general education purposes only. The information
contained in these materials, lecture, ideas and concepts presented is not
intended to be, and is not, legal advice or even particular business advice
relevant to your personal or medical practice circumstances. The laws,
regulations and contractual terms regarding auditing that is presented in this
lecture are published by state, Medicare contractor or in a relevant carrier
policies/contract and are open to interpretation. It is your responsibility to policies/contract and are open to interpretation. It is your responsibility to
evaluate relevant carrier medical policies and provider contract provisions as
Well as to seek private counsel with your attorney to determine how these
laws, regulations, policies and contractual terms as well as the concepts
discussed apply to your specific case before applying the concepts addressed in
This presentation. Attendance at this presentation should not be construed as
legal advise by the speaker nor will the information prevent any audits/fines or
sanctions by any entity. Remaining for this presentation indicates your
acknowledgement and agreement with the above.
Difference between EMR and EHR?
Common problems encounter through EMR audits
C d P t– Copy and Paste
– Auditing concerns of History, Exam and MDM
– Medical Necessity
How has it affected our physicians and patients?
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How is system configured and set‐up?
Be aware of what areas that could b t ti l bl be potential problems or concerns for your practice
EMR verses EHR
–EMR (Electronic Medical Record)
• Patient information relavent to encounter
–EHR (Electronic Health Record)
• Data from all other sources
EMRs increase your risk of an audit—unless you use the system’s documentation features properly
EMR notes should essentially mirror handwritten documentation
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Number one risk for fraud/abuse
Problems?
– Identical notes
– What was actually performed during What was actually performed during encounter
Copy and paste is a big problem with EMR systems
It is considered fraud according to DHHS
Passing off as current documentation can Passing off as current documentation can lead to many errors/treatment
Problems
–ROS needs to pertinent to the chief complaint
Example of problems with copy and Example of problems with copy and paste:
– Documentation states:
• “Sutures healing well”
–Reality:
• The patient had sutures 1 year ago
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Documentation that is verbatim and obviously cut and pasted or cloning would not stand up in a court of law.
Wh t i t d t ?What is true and accurate?
Selling point
–Ease of documentation
Saves time and is convenient
–Problems:
•Risk of fraud/abuse
•Could compromise patient care
2013 Work Plan
OIG states
–"Medicare contractors have noted an increased frequency of medical an increased frequency of medical records with identical documentation across services“
Other payers will follow the same guidelines
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Per CMS guidelines
– The medical record should clearly reflect the chief complaint
– Supports medical necessity for the visit
Per CMS guidelines
– The medical record should clearly reflect the chief complaint
– Supports medical necessity for the visit
Per CMS guidelines
– The medical record should clearly reflect the chief complaint
– Supports medical necessity for the visit
Problems
– Follow‐up
– None listed
Problems
– Follow‐up
– None listed
Problems
– Follow‐up
– None listed
Systems not set up well in this area
Problems
– No detail of HPI – limited information
– Unacceptable terminology Unacceptable terminology
• Endocrine system
– 3 Chronic problems
ROS and PFSH taken by ancillary staff or patient intake form
Problems– Review by physician?– Review by physician?
– Date and location of previous information reviewed
– How is this documented
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System Set‐up
– Terminology
Problems
– All others negative– All others negative
–Unremarkable/non‐contributory
–Notation of abnormal findings
Unobtainable history
Problems
– Why unobtainable – free text?
– Medical necessity of history obtainedMedical necessity of history obtained
95 guidelines
Problems
– How is detailed determined in EMR
– Body areas verses body systems Body areas verses body systems
– 4 x 4 method (Novitas)
– Abnormal findings
– Unremarkable
– Medical necessity of exam
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Diagnosis
Problems
– Chronic problems not addressed or pertinent to visit/diagnosis
– Secondary ? How does the computer know?
– Examples
• Diabetes and ulcer?
• Sinusitis and chronic lumbar back pain?
Interpretation
Problems
– Credit for order/review or actual interpretation
– History obtained by someone other than History obtained by someone other than patient
– Discussion with another provider
– Old record reviewed
Prescriptions
Problems
– RX given for OTC drugs
– Ibuprofen 800 mg counted as RX?Ibuprofen 800 mg counted as RX?
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History, Exam and MDM
Problem
– Does your computer have a brain to decipher the medical necessity?p y
EMR set up to decipher 2 out of 3 components
Problems
–High level of service for minor High level of service for minor problems
–Comprehensive History and Exam with low Medical Decision Making
Problems
– Created by someone else
– Not designed for physicians own methodology, individual style
– Legally dangerous
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Over‐documentation
– Cutting/pasting
– Check off boxes
Under‐documentation Under documentation
– Thought processes
– Whole story
Diagnosis
– Highest level of specificity
Cannot obtain PFSH because they are a child
Patient’s PCP counted as PFSH
Blanks in documentation not completed
“History of” listed in ROS and counted
Misspelled words
Incomplete sentences or sentences that make no sense
Counting a complete exam when patient is uncooperative or unable to obtain
HEENT used for ROS ‐ negative
Judgment and insight for 3 year old
Patient with ringworm – 99214
Contradictory information in HPI and ROS Contradictory information in HPI and ROS
Every exam
– Hearing test
– Gait and station
– External exam of ears/nose
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CC: cough, sinus 2 year 3 month old male present with complaints of,
patient brought to the clinic by mother. Complains ofestablished patient of ABC clinic. Associated symptoms: headache. Denies allergies, chest tightness, wheezing, shortness of breath, sore throat, ear or eye symptoms. A i t d ith f l i tit Associated with: fever, myalgias, poor appetite, nausea, vomiting diarrhea, chest congestion, chills.
Complains of??? Associated with for fever, myaligias, etc does this mean they were positive or negative. Very little information to support cough and sinus.
Interruptions
To easy to check off boxes
Burden on physicians doing data entry
Lack of cooperation Lack of cooperation
– Software companies
– Administration
– Providers
Finding scanned information
Medicare is concerned that defaulted documentation may cause a provider to overlook significant new findings resulting in patient safety/quality issues
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Problems
– Are all the doctors using them uniformly
– Build into computer?
– Acceptable?p
• Buzz words
• Problems
• Computer doesn’t recognize words
D t d thi th t did ’t h • Documented something that didn’t happen during the patient visit
Diagnosis Code Searches
– Example: Diabetes with manifestations Problems
– Using unspecified codes or using incorrect di i d diagnosis codes
– Adding E codes or drugs and chemical codes– Alphabetizing the list of diagnosis codes
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Tracking in and out of providers – right person is logged in for document
Problems
– Not changing from MA/nursing entering Not changing from MA/nursing entering information to doctor
– Doctors giving out passwords to MA’s/nurses
Sign each note and must be legible
Problem– You could end up under the microscope for an audit
N t ll i d– Not all pages signed
• Subsequent visits
Dates should coincide
Problems
– Dictation date before encounter date
Example:
– Patient admitted 3/23/13 but dictation is for 3/22/13
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Detail of procedures performed
Problems– Dosage documented incorrectly
N t h d t il LT RT d t i l – Not enough detail LT, RT and anatomical information
Selecting from drop down boxes
–Verify, verify, verify
Problems
Select incorrect drug or diagnosis–Select incorrect drug or diagnosis
–Could be a malpractice issue if not corrected
Free form texting ‐ good, then the note is not cloned
–Reviewed by auditors
Problem
– Does the EMR identify and pick up this information for history, exam and MDM?
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Problems
– Time not listed for codes that are time based
• Hydration
• IV
• Critical care
• Prolonged service
• Care Plan Oversight
Problem
– One system was identified that the system automatically defaulted to established patients unless changed by the physician
Interface correctly with billing EMR.
–Are charges crossing over appropriately ?
– Use a dummy code to for coders to follow throughthrough
Problem
–Edits to catch problems or fix problems such as work queues
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Scrambling to setup EHR systems
Problems
–Physical, User, System and Network Security Security
– Documentation guidelines
–Billing • CPT
• ICD‐9
Agreement among providers of grey areas, and documentation
Auditing compliance plan
April AAPC Cutting Edge April AAPC Cutting Edge
Auditors should be involved
Identify and correct some of those problems identified
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PROS
Easier to monitor for medication use, patient compliance, changing symptoms, immunizations recall notices automatic immunizations, recall notices, automatic reminders and alerts, and other factors
Quick access to other offices and hospitals
CONS
–Systems can be difficult to learn
–Time it takes to enter information
–Computer down time
Systems fail to recognize word due to misspellings
Takes more time to click through screens than use a pen and paper to screens than use a pen and paper to order tests
Difficulty in finding important information
Searching for CPT and ICD‐9 codes
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Not as personable
Computer systems is taking the attention from the patient
Results in poor bedside manner
Talking less?
Patients not convinced their medical records are safe from others
Not waiting for dictation
Interface with other providers such as hospitals, etc to retrieve information immediatelyimmediately
Legibility
Potential problems within your EMR systems
Medical Necessity
Computer is not a Human Brain
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With automation
comes danger !!!!
Property of Career Coders, LLC. All rights reserved. These materials may not be duplicated
without the express written permission of Career Coders, LLC -© 2013
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