EHR Documentation: Compliance Issues

Transcription

1 EHR Documentation: Compliance Issues Kris Cuddy, CPC, CIMC 1

2 Traveling Documentation Traveling documentation means PFSH and/or ROS that moves forward to each new date of service with the same provider (or specialty group) and the same patient. Just because it travels doesn t mean it s pertinent or correct information. 2

3 Traveling Documentation As a coder, or auditor, recognizing traveling documentation is important in selecting the correct level of E/M service. Coding for the doctor/mid-level provider: Can impact the actual intent of the doctor/provider E/M level Auditing the doctor/mid-level provider: Can impact the results 3

4 Traveling Documentation So what do you do?? Whether you are a coder or an auditor, it is important to first determine if there is traveling documentation in the EMR. If yes, have a conversation with either the provider or the practice manager about how the traveling documentation is considered in the provider s E/M selection, e.g., Is it just there in case they want to look at it? Do they believe an E/M code is dependent on how much documentation is in the note? Is there something additional you should look for when deciding whether to count it during coding or audit? 4

5 Traveling Documentation Don t forget to discuss how either your HIT staff, or the EMR support staff, can turn the switch off to not travel for future documentation. Don t let the EMR vendor fool you Traveling documentation can always be turned off 5

6 Cut-and-Paste Documentation Cut-and-paste documentation is where a doctor/provider will copy documentation from a prior date of service and paste it into their current documentation. OIG and CMS are watching this closely. 6

7 Cut-and-Paste Documentation OIG has detailed the following intentions in their 2011 Workplan: We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS s Medicare Claims Processing Manual, Pub. No , ch. 12, instructs providers to select the code for the service based upon the content of the service and says that documentation should support the level of service reported. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. 7

8 Cut-and-Paste Documentation Problems with cut-and-paste: Doctors aren t reading the entire segment pasted in and there are parts that do not belong with the current date of service Multiple cut-and-pasting of the same passage with changing of a few words at the beginning and a few words at the end again, parts in middle may not be current Loss of present conditions, signs, symptoms, examination, review of systems, etc., being documented accurately 8

9 Cut-and-Paste Documentation If your doctors/midlevel providers cut-and-paste in the EMR: Remind them that they need to read the entire segment being cut and pasted When the doctor/provider electronically signs EMR documentation for a visit/service, they are advising they have read the entire document and agree with all of it. 9

10 Under-Coding If you are a coder, or auditor, performing chart audits, or reviews, and find under-coding a consistent battle since using an EHR, here are some things to know and questions to ask the provider: In relation to the nature of the presenting problem, Was the level of past, family, and social history, medically necessary? Was the level of review of systems medically necessary? Was the level of examination medically necessary? 10

11 Under-Coding OIG and insurance carriers consider under-coding the same as over-coding. Especially in regards to carriers (like Medicare) who reimburse on a percentage scale, where it could be considered as giving care at a lower cost than what was truly provided (so the patient would pay a lower percentage out-of-pocket coinsurance). 11

12 Thank you for attending today s Webinar. Check Out Our New E/M Page: Free Coding Advice for All SuperCoder Subscribers. Coming to SuperCoder.com Specialty Corner Home Pages in August. 12

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