It’s not unusual for a doctor to pick up any trade journal and read about how electronic health records are the end all and be all in documenting services and maximizing reimbursement. The U.S. government has encouraged physicians around the country to transition to EHRs offering billions of dollars in incentive payments. These systems have been touted to increase efficiency, improve care, and reduce costs in the health care industry.
But new information is being released by the U.S. Department of Health and Human Services warning that increased use of improper documentation standards in EHRs may lead to an increase incidence of Medicare fraud. The letter warns against cloning medical records, which could lead to up-coding claims and improperly inflating reimbursement. In January, the Office of Inspector General issued a report flagging EHR related fraud as a problem. This will almost assuredly trickle down to commercial payers who are constantly looking for reasons to request refunds for over-coded services.
I provide hundreds of record reviews each year and I’m seeing a similar trend in documentation. Many of the documented visits are looking the same as the previous one. With the increased use of EHRs, the OIG is growing concerned with the increased frequency of medical records documenting the same information regardless of the nature of the presenting problem. The OIG is evaluating multiple records for the same provider to determine the extent to which documentation problems exist. They are cracking down and penalizing physicians who duplicate documentation in this fashion. Physicians must be cautious when they pull information from previous visits or repeat documentation regardless of the presenting problem. Records should be specific and unique for each visit.
Here are some things to watch for as they may be causing significant problems in your practice.
Copy and Paste
It’s so simple. Just copy and paste, right? Wrong. Doctors love this easy mechanism for repeating information—maybe too much. Many doctors feel that more information in the record means the documentation must be better, which means they should be able to bill for higher codes. This mindset creates a serious fraud risk.
For example, established patient visits require only two of the following: history, examination, and medical decision making. If you copy and paste information from a previous visit and this increases the level of history and examination, the code choice could be higher. However, if the problem presented that day was something simple such as a thumb injury, it would not be appropriate to document a high level history or examination for this type of problem. This is where additional but unnecessary documentation is a mistake and can be interpreted as fraudulently attempting to increase payments.
Electronic systems have functions now that allow the user to insert standardized text into the medical note. These “macros” can make it easy for doctors to complete their records each day, but pre-determined scripts can backfire and cause records to look exactly like previous documentation causing more scrutiny. I’ve seen this problem most often in the history of the present illness and review of systems where the HPI documents the presenting problem, but the ROS states that the patient does not have any of the symptoms discussed previously in the record. The record appears to have been pre-populated for all of the systems to be reviewed and no one bothered to change it to ensure it is consistent with the rest of the record or the nature of the problem. Doctors must ensure that the entire record is consistent and appropriate.
Nature of the presenting problem
I’ve seen many records that may meet a higher level of history or examination but the medical decision making falls short. The medical decision making is made up of the number of diagnoses and management options, the amount and complexity of data ordered or reviewed, and the risk. These elements are important in code choice regardless if the patient is new or established. I would also suggest that the risk can be considered the most critical issue in determining code level. A patient may present to the office with a minor problem that is quickly diagnosed including over the counter treatment recommended. The record can be over documented for the history and examination, but what really must drive code choice are the limited diagnoses, limited data reviewed, and straightforward risk. The code should be billed as a low level. I consistently have to train physicians to understand medical decision making and the work involved for the visit. Recognizing that this is the element that ultimately drives code choice has to be a significant factor when selecting a code.
Things you can do to prevent your EHR from exposing you to fraud and possible refunds includes following these recommendations:
- If you use an automated text function, don’t assume it will be consistent with the other information in the note. Read the note to ensure that it flows and is consistent with what you are trying to communicate. Make sure the record does not include extra or unwarranted information.
- Ensure each record stands alone and is unique from the previous patient or visit. Don’t let records look the same.
- Read your assessment and plan and ask yourself: “Is the information contained in the history and examination relevant for the nature of the presenting problem?” If you answer yes then you have the required information for the problem presented. If the answer is no, remove unnecessary information that doesn’t have any relevance to the current problem.
- Consider the medical decision making (number of diagnoses, complexity of data, and risk) to be the most critical elements in code choice. Ensure these elements are met.
- Consider an educational record review audit to determine the elements that need improvement. Help train doctors with weak documentation ways to document more effectively. This will help ensure more consistent documentation and help avoid refunds or questions of fraudulent behavior.
Compliance with medical record documentation is crucial to avoid suspicions of over documenting or up-coding. It’s not a matter of whether they review your records; it is a matter of when. Be prepared by having your records reviewed to understand areas of weakness and what needs to be improved. The government and commercial payers are relying on those inside the medical community to take a stand against abuse. It starts with you.