The following is a guest post by Deborah J. Robb, BSHA, CPC. You can read more of Deborah’s work on her blog.
Deborah has served TrustHCS since 2007, where she developed the professional services department providing physician coder education related to CMS guidelines. She has also managed 34 coding staff that provide coding services to a variety of multiple specialty clinics nationwide. With over 35 years in the healthcare profession, she is a frequent speaker on Medical Coding, including appearances at State and National AHIMA conferences. Deborah is also a five time author for Direct Learning On-line courses in Medical Terminology and Medical Coding and has written numerous articles in national publications including, but limited to, For the Record, Physician Practice Magazine and Journal of AHIMA. Deborah is a graduation of Central Texas College and Columbia Southern University.
The OIG is concerned that inappropriate E/M service payments may be linked to cutting and pasting encounter notes within EMRs. As a result, their 2013 Work Plan includes the identification of redundant documentation and improper billing of multiple E/M services. Practices can mitigate their risk of OIG audits and fines by implementing the following five steps for proper E/M level documentation within an EMR.
Red Flag Redundant Documentation
Practices should conduct regular reviews of physician documentation to ensure duplication is kept to a minimum. Reviews should include a broad sample of E/M services and compare each provider’s results. Findings and anomalies can be discussed as a team with results used as a learning tool to improve documentation, coding and billing practices.
Two particular areas for review include error rate for incident-to services performed by non-physicians and the E/M coding of “new” patient for patients seen prior. The “incident-to” designation pertains to services and supplies performed incident to the professionals services of a physician. When Medicare first took a look at these billings, they discovered half of the services delivered and billed were not performed by a physician. The OIG will review “incident-to” services to determine whether payment for such services carries a higher error rate than that for non-incident-to services; or if redundant documentation is to blame. They will also be assessing Medicare’s ability to monitor such services.
Secondly, Medicare contractors have identified the use of a “new patient” E/M code for patients seen within three years by the same provider or within the same practice as an area of scrutiny. Internal audits and documentation reviews should include both of these OIG issues.
Evaluate Cut and Paste Policies
Practices should also assess organizational policies and procedures around cut and paste functionality. Initial EMR implementations promoted copy/paste with little foresight into the downstream documentation, coding and billing issues. Policies and procedures should state what is acceptable to be brought over from previous notes. Practices are encouraged to consult the American Health Information Management Association’s (AHIMA) Copy Functionality Toolkit. It includes valuable case scenarios, sample policies, checklists and audit guidelines.
Raise Awareness of Risk
The ability to copy and paste a patient note from a prior visit into a new encounter is so easy within most EMRs, that providers may unknowingly risk patient safety. The following risks are noted within the AHIMA toolkit and should be shared with all documenters.
- Copying information into the wrong patient chart
- Inaccurate or outdated information
- Inability to determine current information
- Inability to identify the author or intent of documentation
- Inability to identify when the documentation was first created
- Inability to accurately support or defend E/M codes for professional or technical billing notes
- Propagation of false information
- Internally inconsistent progress notes
- Unnecessarily lengthy progress notes
Implement Clinical Documentation Improvement (CDI)
Similar to hospital CDI initiatives, an effective CDI program for physician practices includes phases for assessment, education and monitoring. Findings from initial assessments and ongoing monitoring should serve to focus education and training efforts throughout.
Every Encounter on Its Own
Finally, every encounter’s documentation must stand on its own. There must be valid documentation within each note to support the visit. Questions to ask of each note include:
- Does the documentation prove the visit was done?
- What has changed from the previous visit?
- Does the documentation demonstrate what was done?
Cut and paste saves time for clinicians, but may unintentionally skew E/M documentation, coding and billing. The review of this practice within the 2013 OIG work plan is a significant motivator for practices to tighten policies and mitigate risk.