Coding consultants explain where the risks are and how to avoid them.
It's long been known that physicians tend to code higher for office visits after they get electronic health records (EHRs). But now Medicare and private payers are taking an active interest in this trend, and audits of computerized practices are becoming more frequent. So if you have an EHR, be very careful how you code, say coding consultants.
Joan Gilhooly, a consultant in Deer Park, Ill., cites the case of an internist who was billing "a substantial number" of level 4 visits. A Medicare audit showed a pattern of nearly identical information in all of the records reviewed in his EHR. This physician appeared to be documenting a complete physical, a review of systems, and a family and social history in every encounter. He was potentially facing not only a civil charge of upcoding, but also the possibility of criminal fraud charges. Fortunately, his lawyer managed to establish that none of this was intentional: The physician's poorly trained staff had simply pulled in information from previous records for the doctor to consult when he saw each patient. So in this case, the government settled instead of going forward with the case.
Gilhooly tells this story to caution physicians against purchasing EHRs in order to increase their revenues. That may be a side benefit if they've been undercoding all along, as many doctors do. But that isn't why they should buy an EHR, she says. Vendors who promise that physicians will see a big return on investment from more appropriate coding, she maintains, just aren't paying attention to the Medicare coding rules.
Virginia Martin, a consultant in Waterville, Ohio, says she's done internal audits of EHR-equipped practices that documented comprehensive exams and past histories when patients visited for minor problems. "The medical decision-making is really what determines the level of care; the history and the exam should be appropriate to the presenting problem," she says.
Having staffers take most of the history is one reason why documentation goes awry, she adds. "Staff members can perform certain portions of the patient encounter, and they should not go beyond that."
OVERDOCUMENTATION can also be related to how a physician uses an EHR, Martin points out. If a physician implements the system without customizing the EHR templates to his practice style, "the templates may contain more information than what he's used to documenting. So it appears that the history and the exam are more complex, but the medical decision-making level is low."
Martin and Gilhooly both advise physicians to spend time building their templates. "Be brutally honest with yourself," Gilhooly adds. "Saying that you typically do an eight-organ system exam on every patient who walks in the door isn't being honest with yourself."
Pulling in past notes and charting by exception
You can often speed documentation, Martin points out, by copying part of an earlier visit note that deals with the problem at hand. "So if it's a routine hypertensive checkup after 3 months, it's not necessary to redocument; you just go back and edit what's different. The problem is that some doctors are so busy that they don't go back and edit appropriately. They're ordering labs or other tests, and there's no support in the documentation for the ordering of those tests. Or they bring the last visit over to the EHR, and now the patient has a new complaint that's never addressed in the note: for instance, chest pain or arthritic changes."
She also cautions physicians about a common practice known as "charting by exception." In this approach, the doctor sets up the EHR to record normal findings except where he indicates that they're abnormal. While this can facilitate documentation, it's essential to edit these documents carefully to make sure that you actually performed every item.