Written by Dawn Landry, CPC
The current healthcare environment continues to create regulatory complexities so physicians are forced to reduce patient time and focus on regulatory and administrative issues. Keeping a clinic or health system compliant has become the forefront to avoid government and private payor audits. As physicians try to create efficiencies with implementation of Electronic Health Records/Electronic Medical Records (EHR/EMR’s), a new vulnerability to government scrutiny begins to evolve.
In an attempt to make physicians more efficient, some EMR software products auto-populate certain areas of the medical record. One example of this auto-population is the active problem list defaulting down to the assessment and plan (A/P). While the active problems are relevant for decision-making, they may not be the main reason the patient presents to the provider. If billing staff can’t cross check or validate the reason for visit against the A/P portion of the note, incorrect information may be sent to the insurance company. The EMR vendors market this auto-population functionality as a time saving factor for the physician, however use caution as the payors, including Medicare part B, are taking notice and down-coding or sometimes denying these patient claims.
Medical necessity should be the driving factor of all visits. The Medicare Claims Processing Manual, chapter 12, section 30.6.1 defines medical necessity as “the overarching criterion for payment in addition to the individual requirements of a CPT code.” Credit cannot be given for information that is not patient specific and date of service specific. While using a template is acceptable, it’s important to remember that it would not be adequate to list that the same patient has the same exact problem, symptoms, and management for each visit. If an auditor reviews this type of documentation in a note, it could lead to a denial of the service for lack of medical necessity.
CMS has authored several recent articles focused on auto-population or “cloned” data fields. Cloned documentation refers to documentation that is worded identical to previous entries. Other terms for ‘cloning’ could be ‘cut and paste’ or ‘carry forward’. In some cases, an auditor will review a Review of System (ROS) carried over from a previous note and determine that it contradicts the History of Present Illness (HPI) of the current visit. For example, the HPI may document “the patient presents for nausea and vomiting for three days…” yet the ROS for GI will state “no nausea or vomiting.” This contraindication may cause the encounter to be questioned for medical necessity and level of service (E/M) that was billed.
In addition, some EMR’s incorporate tools with auto defaults to save the physician time, which can also lead to problems. An example of this is often seen in the history area where the physician document; “I have reviewed the past, family and social history.” However, audit findings show that these functions are not always performed at each visit as documented.
Another problem seen in EMR documentation is excessive documentation. An EMR system may allow a provider to ‘point and click’ through bullet points on a template unknowingly navigating to a higher level of service. For example, clicking though a template to obtain a comprehensive history and exam for an established patient who is presenting for a straightforward problem, such as an insect bite with no other complaints, could lead to a denial for medical necessity.
Use caution when clicking through a template. Take your time and remember each encounter could be the one you have to defend on the witness stand. Ensure documentation is specific to the problem the patient is presenting for each date of service. It is important to review notes carefully before closing or authenticating to ensure all the information is correct and pertinent to the presenting problem. Finally, remember it’s not the quantitative elements of an E/M; it is the qualitative elements that count to support the medical necessity of the visit.