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Documentation and Compliance
with the Electronic Health Record
Where Is The Medical Necessity?
Susan Roehl
Health Care Consulting Manager Fargo, ND
The EHR and Meaningful Use
• Meaningful use = incentive payments
• We can meet the criteria of meaningful use,
but…….
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The EHR
• March 20, 2012 – Noridian – Electronic
Health Records and Future Audits
• (We don’t like audits!!)
• “Since EHR systems commonly
auto-populate and duplicate information, providers must ensure all components of the billed E/M and other visits are medically reasonable and necessary, based on the presenting
complaint and not on the type of information documented”.
The EHR
• Sources: 42CFR Parts 412,413, 422
Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Medicare and Medicaid EHR Final Rule
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CMS and the EHR
• Progress notes and templates –
• “Some templates provide limited options and/or space for the collection of information such as by using “check boxes”, predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review
experience shows that limited space templates often fail to capture sufficient detailed clinical documentation to demonstrate that all coverage and coding requirements are met”. (Transmittal 438, 11-9-12)
• We will discuss this entire Transmittal later
-CMS and the EHR
• Financial Liability
• “The physician/LCMP should be aware that
inadequate medical record documentation can lead to financial liability for the
Beneficiary and/or Supplier, should the reviewer determine that a claim is not supported.”
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CMS and the EHR
• September 24, 2012 letter from USDHHS
and USDOJ to AHA and other Associations:
• “However, there are troubling indications
that some providers are using this
technology to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it’s illegal……”
CMS and the EHR
• “These indications including potential
‘cloning’ of medical records in order to inflate what providers get paid. There are also reports that some hospitals may be using electronic health records to facilitate
‘upcoding’ of the intensity of care or severity of patients’ condition as a means to profit with no commensurate improvement of the quality of care.”
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CMS and the EHR
• “We will not tolerate health care fraud”. • Does the EHR promote fraud?
• Without extensive free text it does not promote objective documentation and assessment. • It does promote “upcoding” if the provider “clicks”
all the boxes or autopopulates the fields without asking the questions or if they are not pertinent to the assessment.
Autopopulation
• For example, the automatic generation of
common negative findings within a review of systems for each body area or organ system may result in a higher level of service
delivered, unless the provider documents any pertinent positive results and deletes the incorrect auto-generated entries.
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As Early As 2003
• NAS has noticed an increase in the use of
software-generated documentation for chiropractic services. On this subject, CMS states:
• "Documentation should detail the specific elements of the chiropractic service for this particular patient on this day of service. It should be clear from the documentation why the service was necessary that day. Services supported by repetitive entries, lacking encounter specific information, will be denied."
As Early as 2003
• “In general, most computerized
documentation, regardless of the software used, fails to provide individualized
information necessary for reimbursement.
• Software-generated documentation is
commonly identical to the letter, comma, and space for different patients, with only minor word changes; therefore, it does not reflect medical necessity. Services supported by repetitive entries lacking encounter
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As Early as 2003
• “Daily notes need to be encounter specific for
each date of service and contain both qualitative and quantitative elements evident for the
subjective and objective portions of the documentation. Without this information, it is difficult for a reviewer to assess the true clinical picture of the patient, in regard to the severity of his/her condition. What may be appropriate for one patient, may not be enough or required on another patient or visit”.
.
As Early as 2003
• “Factors that must be taken into consideration
when treating and documenting: • Age
• Severity of condition
• Past response to treatment
• Frequency of treatment
• Complicating factors
• Software-generated documentation often repeats
the same phrases and sentences by simply rearranging the words to make it appear as if new information is being disseminated, but when compared to prior days notes, reflects the same or similar concepts”.
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Do you see what I see?
• Daily progress notes that are a “clone” of the
previous day’s documentation = red flag
• Resolved issues documented as if they were
still current
• Templates that indicate all “negative” or “no”
• Why is the patient here?
• Where is the medical necessity?
Do you see what I see?
• Patient treated in ER for a small finger
laceration
• Every Body System in the Review of Systems is addressed
• A head to toe Physical Examination is documented
• REALLY??
• Non-medically necessary system reviews and
examinations should not be included in the Evaluation and Management level assignment
• Do your Providers know the E/M guidelines? • Do your coders know the E/M guidelines?
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Do you see what I see?
Previous eye enucleation• Review of Systems – Eyes – “Normal”
checked
• Physical Examination – “Pupils react to light
and accommodation” checked. “No significant findings” checked. Really?
Do you see what I see?
• Patient with a previous above knee
amputation right leg
• Review of Systems – Musculoskeletal “No reported symptoms”
• Physical Examination – Extremities
“Good muscle tone and strength bilateral. Gait normal”. Really?
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The Dangers of Copy and Paste
• Cut and paste, copy and paste, cloning, carry
forward – whatever you call it – may
misrepresent the patient’s current condition
• Contradictions are seen throughout the
record when copy and paste is utilized
• When a provider brings forward other
clinicians and nursing documentation, he is taking responsibility that it is correct
The Dangers of Copy and Paste
• An entire progress note that is copied and
pasted or brought forward does not signify any involvement of this provider in the patient’s assessment and care for that date
• (other than they have acquired some technology skills )
• There is no reportable service for the
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The Dangers of Copy and Paste
• Documentation is critical
• To support an admission from Observation
to Inpatient status
• To support a one or two day Inpatient stay • To support the medical necessity of a
surgical procedure
• To support Lab and X-ray procedures
Integrity of Clinical Documentation
• Medical necessity concerns are not new with
the EHR
• They are compounded by a record in which
templates and check boxes are the only documentation present on the record
• Physician documentation that was
substandard in the paper record is not improved in the EHR
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Integrity of Clinical Documentation
• Data quality and information integrity must
be prioritized. “If clinical documentation was inaccurate when used for billing or legal purposes, it was wrong when it was used by another clinician, another provider at
transition, a researcher, the public health authority, or quality reporting agency.”
• AHIMA ‐In testimony before the Office of the
National Coordinator HIT Policy Committee,
made its case that suboptimal clinical
documentation in the EHR is a problem that
needs addressing. February 2013
Integrity of Clinical Documentation
• A study reported in the July-August 2004 issue of theJournal of the American Medical Informatics Associationmeasured the impact of computerized
physician documentation at a teaching hospital. The authors, who interviewed resident physicians and faculty, identified the following three problem areas:
• Redundancy: The same information and misinformation was repeated. It was also difficult to identify where the misinformation began.
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Integrity of Clinical Documentation
• Formatting: Staff had trouble segregating
useful information—”stuff you care about”— from meaningless data in the endless notes.
• Decreased confidence in the material:
One person interviewed said the progress notes made it appear that the same physical exam was performed by an intern, a resident, an attending physician, and a subspecialist.
Cluttered
Paper notes were 90% clutter free – “People didn’t put gibberish in hand written notes”. EHR’s on the other hand, have 60% clutter in them. “Clutter is stuff on the page with no value added to it”.
Brian Jacobs, MD, Executive Director Children’s National Medical Center CIO and CMIO
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The Problem Problem List
• The Problem List - a requirement of
meaningful use
• But, does it have any meaning?
• The EHR does not prompt the provider to
add (or chose not to add) diagnoses to the Problem List, at least in the hospital setting
• This can become automated in some
systems. It should always be a provider decision
The Problem Problem List
• “The problem list is for nontransitive illnesses.”
• This is the official definition used in the Federal
Meaningful Use program.
• Most providers ignore the Problem List because: • It is not current or valid
• It is not consistent • It is not maintained
• Whose responsibility is it? • Nurses add to it
• Coders add to it
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EHR Shortcomings
• Physician documentation in the EHR has
been designed for reimbursement purposes, as opposed to documentation of specificity, complications, and comorbidities
• Meaningful use requirements have been built in
• Nursing and ancillary documentation in the
EHR has been designed to check all the boxes for State and JCAHO requirements, as opposed to reporting a clear picture of the patient's condition
Legal Aspects
• Potential for bringing forth billable procedures
that were not performed at this visit
• Copy and paste in the record decreases the
credibility of the record from an auditing and medico-legal aspect
• Lack of editing, auditing, and review creates
chaos in the record
• What would a lawyer do with this record?
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Once an error, always an error
• Information that is incorrect, and then is
auto-populated, brought forward, or copied and pasted takes on a life of it’s own
• Drop down boxes are great assistants, but a
wrong click is there to stay
• An incorrect drug allergy is now populated
throughout an entire medical record
Payers are taking note
• Noridian • Palmetto
• First Coast Service Options • Aetna
• Indian Health Services
• National Government Services
• All have published statements or policies regarding
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OIG
• "As systems transition toward quality- and
outcomes-based payment systems, law enforcement will be presented with new challenges. Investigators will need the skills to determine the reliability of data used for measuring quality and performance because false data could skew payments."
• –Daniel R. Levinson Inspector General
• In the Justification of Estimates for the Appropriations Committee
ICD-10 and the EHR
• The EHR should assist providers with the
detailed specificity required with ICD-10
• However, the systems were designed without end user input, especially from the coding community
• Verify with your vendor the EHR will be
updated to accept ICD-10 codes and documentation
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ICD-10 and the EHR
• Custom templates and drop down boxes
SHOULD include the details required (i.e.)
• Initial or Subsequent visit, or Sequela • Right or Left side
• Specificity per fracture site – which finger (1-4 or thumb), which part of the finger (distal, shaft, proximal)
• Detailed documentation = detailed severity of illness documentation!
Worse Case Scenario
While Patient A was a patient at Medical Center A, a number of medical tests and diagnostic evaluations were performed in an outpatient clinic over a two-week period.
Concern arose about the health plan claim, so Patient A requested a copy of his medical record along with the bill for services. The statement included Evaluation and
Management codes consistently reported at the highest level of service (level 5).
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Worse Case Scenario
Because Patient A is a retired auditor for health plans, he examined the documentation and discovered that the medical history was pulled through within departments, between
departments, and in subsequent visits with the same provider using the Electronic Health Record (EHR) system, even when the visits did not include the clinician taking a history. The health plan was billed for a high level of service (of history) for each hospital outpatient clinic visit.
Worse Case Scenario
Patient A is concerned that the EHR does not have the functionality (or it is not used) to show that the history (or any documentation component) obtained during a previous encounter was copied and reused as documentation for subsequent visits to support physician intensity of service. After many attempts to have services billed at the correct level (what Patient A insists is really a level 2 or 3 Evaluation and Management when the pulled through data are not considered for service intensity), he contacts the fraud division of the health plan about his concerns.
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Bad Example
• The EKG order is in the electronic order
format only, and it does appear to be signed by the physician. The indication for the EKG on the telephone order is “chest pain”. This is the only documentation on the record of chest pain that we could locate. There is no nursing documentation that corresponds with the time of order, and the pain assessment two hours prior was “N” in the “archived Discharge Summary” nursing documentation portion of the electronic record, which is over 40 pages.
Bad Example
• There are additional “archived notes” two
pages of nursing notes with free text that includes one note which states the patient has chest pain. This is not included in the 40+ pages as noted previously?? Chest pain is not included in any physician
documentation, including the progress note for that date. We do not recommend
reporting chest pain (786.50) which is only documented in a telephone order.
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Bad Example
• IV Levaquin was started at 1402, but there is
no documentation when it was discontinued (patient suffered an adverse reaction) on the Medication Discharge Summary. In the
Archived Notes document timed 1419,
nursing states IV Levaquin was discontinued; however, we cannot determine if this is the time of the note or the time the Levaquin was discontinued. Report 96374 – IV push,
initial, due to the lack of accurate documentation.
Policy and Procedure Needs
• Abbreviations
• ICBG - ? Iliac crest bone graft. Documented by a hospitalist on 5 fusion records, however, none had this procedure
• ED physician - Patient being treated with Augmentin for “PNA”. PNA is not a standard abbreviation - does it indicate pulmonary nodular amyloidosis, or pneumonia, or one of the other several potential translations of PNA?
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Policy and Procedure Needs
• Voice recognition software
• Training of software required
• Approval per individual employee (following documentation review) recommended
• “Subjective – patient states that she fell on naproxen marcated injured left shoulder” • “His blood pressure a first person labile that
after has not been intubated and sedate it has normalized”.
Policy Statement Example
• Electronically signing documentation
containing nonsensical or grammatical errors.
⇒ Do not sign clinical documentation that
contains grammatical errors, nonsensical statements, or incomplete information. Your electronic signature is a confirmation that the medical record note is accurate, complete, and free of omissions. Noridian encourages providers to proofread all documentation prior to signing the note to avoid potential payment
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Policy and Procedure Needs
• Copy and Paste
• Limited use recommended
• Carry Forward
• Last visit note is brought forward for editing – also very
high risk for inaccurate information and upcoding
• Copy and Paste and Carry Forward only allowed
for the SAME provider or staff member
• Cannot copy or carry forward another provider or staff
member’s documentation as if it were your own
• If Lab or X-ray findings are copied and pasted, they
must be addressed specifically to the patient’s condition and treatment
Policy and Procedure Needs
• Auto-Population
• If the provider clicks a box, automatic detailed examination or history is documented (do NOT recommend) – very high risk
• Our highest level of discrepancy during documentation and coding reviews when compared to other documentation in the record
• Twenty physician records reviewed
• Every visit note contained identical Review of Systems and Exam
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Audits of the EHR
• Since EHR systems commonly auto-populate
and duplicate information, providers must ensure all components of the billed E&M and other visits are medically reasonable and necessary - based on the presenting
complaint and not on the type of information documented.
• Noridian Medicare Part A Electronic Health Records and Future Audits 3/20/12
Policy Statement Example
• Do not use generalized or auto-populated
statements within Evaluation and
Management documentation if it does not support the individual patient’s clinical management. Documentation that contains cloned, identical statements from patient to patient with no evidence of clinical relevance can be perceived as fraudulent when
reviewed by a third party. Such
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Copy/Paste/Carry Forward
• All Copy and Paste and Carry Forward notes
require a notation and date
• i.e., Family History is commonly carried forward, as it rarely changes. Notation “Reviewed and unchanged 06-01-13”
• Past History notation “reviewed 06-01-13.
Updated to note an episode of acute cholecystitis on 4-30-13 from which the patient recovered without surgical intervention”.
Policy and Procedure Needs
• Data Gathering:
• All data carried forward or cut and pasted must identify the source document and date
• Documentation of review of the imported data and it’s impact on the decision making and treatment of the patient
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Policy and Procedures Needs
• Coding Guidelines in relationship to the
review of previously documented data
• Where may information be obtained to assign codes for an episode of care?
• Only documentation present and addressed during the current episode should be utilized for code assignment
Policy and Procedure Needs
• Consistent documentation
• Every staff member documents the same item in the same place
• Medications
• Start and Stop time of infusions and injections • Admission note and time
• Discharge note and time
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The Use of Templates
• “CMS does not prohibit the use of templates
to facilitate record-keeping. CMS also does not endorse or approve any particular
templates. A physician/LCMP may choose any template to assist in documenting medical information”.
The Use of Templates, continued
• “Some templates provide limited options
and/or space for the collection of information such as by using “check boxes,” predefined answers, limited space to enter information, etc. CMS discourages the use of such
templates. Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met”.
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The Use of Templates, continued
• “Physician/LCMPs should be aware that
templates designed to gather selected information focused primarily for
reimbursement purposes are often
insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to
adequately show that the medical necessity criteria for the item/service are met”.
The Use of Templates, continued
• “If a physician/LCMP chooses to use a
template during the patient visit, CMS
encourages them to select one that allows
for a full and complete collection of information to demonstrate that the
applicable coverage and coding criteria are met”.
• Centers for Medicare & Medicaid Services (CMS)
Transmittal 438 Date: November 9, 2012
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Policy and Procedure Needs
• We highly recommend pertinent free text
requirements of both physician/midlevel providers and nursing/clinical staff at least once per day or shift.
• We highly recommend dictated History and
Physicals and Discharge Summaries, rather than templated documents. If a template is adopted, free text in all sections should be required.
Policy and Procedure Needs
• Observation Services
• This is an hourly charge, so documentation
must support the continued medical necessity of this service
• Provider documentation must support the
medical necessity of the need for Observation AND the indications for a transfer to Inpatient status
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Policy and Procedure Needs
• Observation, continued
• Clear documentation of when the patient is away from the nursing floor receiving other services (i.e., Radiology, Physical Therapy, surgical procedures). These times should be subtracted from the
Observation hours.
• Clear documentation of start and stop times of transfusions, chemotherapy, or closely monitored infusions. These times should be subtracted from the Observation hours.
Policy and Procedure Needs
• Policy for copying of medical records
requested by payers and auditors
• Be cognizant of the reason for the request • Do NOT copy all of the electronic record unless
mandated by release of information requirements. One record may fill the back end of a pick up
• If diagnoses codes have been assigned from
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Policy and Procedure Needs
• Release of Information
• RAC, CERT, ZPIC, and other payer audit
requests should be reviewed by UR,
Quality Management, or another employee who can highlight, tab, or indicate in some method where to find pertinent information
• Reviewers will not spend hours looking for
the information they require
Conclusion
• The EHR is a useful tool in health care
documentation, but carries a high risk in upcoding and fraud.
• The medical record has always, and will
continue to be, a medical-legal document. The provider and staff member signatures indicate they are attesting all information is accurate and reflects the care THEY gave.
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Conclusion
• Provider documentation does not need to be
lengthy and cumbersome – it needs to address the condition of the patient and the provider’s assessment, rationale for
treatment, medical necessity AND review of the tests ordered and how they will used in the treatment of the patient.
• Policies and procedures, review of
documentation, and enforcement of policies is required for a compliant EHR.
Questions?
• Sue Roehl, RHIT, CCS • sroehl@eidebailly.com • 701-476-8770
This presentation is presented with the understanding that the information contained does not constitute legal, accounting or other professional advice. It is
not intended to be responsive to any individual situation or concerns, as the contents of this presentation are intended for general informational purposes only.
Viewers are urged not to act upon the information contained in this presentation without first consulting competent legal, accounting or other professional advice regarding implications of a particular factual situation. Questions and additional information can be submitted to your Eide Bailly representative, or to the presenter
