Moving forward with implementation means your participation is vital.
If you thought the introduction of the electronic health record (EHR) would change coding, you were absolutely right. The days of sitting in the back office, appending ICD-9-CM codes to paper fee tickets and manually posting charges is, for some practices, in the distant past. Modern offices expect you to transform your coding knowledge into the fundamental tools used for EHR software development and compliance auditing. With a systematic plan, the right resources, and reasonably sophisticated EHR software, you can be a vital resource in their implementation.
Get Ahead of the Learning Curve
To participate in the development of compliant documentation templates, you must understand how an EHR is designed and how software is modified.
Overall, the EHR should interface with a billing or practice management software so patient demographics data attach to the medical record to avoid ‘wrong patient’ issues. Most EHR software is designed with pre-created templates used to capture patient medical data, document visits and procedures, order prescriptions, and document patient/provider communication—all seamlessly linked to the patient demographics. These templates are designed so providers can enter data through several methods. They can click check boxes or select radio buttons, and choose items from drop down menus to determine the information they want to document in the patient chart. The provider can type additional data within a text box, which displays this information exactly as it’s entered. Other patient data, such as chronic conditions, past medical history, and medication lists can be pre-loaded.
In some sophisticated software, templates can be set up to require some sort of action—almost like an internal email that alerts nursing staff to contact the patient regarding lab results. Other templates can be developed to order a prescription that automatically faxes to the pharmacy. These methods of selection and documentation are elements of a “user interface,” which is a behind-the-scenes mapping of how and where the information is displayed. Taking the time to learn about the behind-the-scenes default “language” that is all part of the EHR package’s user interface will help you determine whether there are options for clear and concise documentation, or if the documentation is limited to certain canned phrases and verbiage.
All EHR software arrives “out of the box” with default data lists that are used to populate the templates to drop pre-determined verbiage into a formatted document based on the provider’s selection. These data lists can include CPT® and ICD-9-CM codes, and place of service (POS) indicators, as well as more customized and editable lists such as office locations, special charges, and fee schedules. Data is typically selected through a drop-down menu.
In all cases, successful EHR implementation depends on the ability to understand, customize, test, and audit the capability and compliance of the EHR software. Coders, today, need to understand the concepts of a user interface, billing rules, and clinical documentation standards, and be able to translate coding and documentation guidelines for successful and compliant software development.
Test the EHR Before Going “Live”
A good software package will provide you with a test environment. When the practice decides to “go live” with a new EHR, there is a period during which the electronically-generated medical record should be systematically audited within a test environment to identify errors or bugs. These problems should be corrected prior to using the EHR in a “live” environment.
By comparing the computer generated notes against an approved audit tool, you can see where the software might be “double-dipping” (counting the same elements twice), pulling forward (bringing arbitrary documentation from another, unrelated note), or creating “bugs,” such as documenting both male and female system reviews for all patients. The completed EHR should meet all of the criteria for a legal medical document. This kind of testing is most effective if planned and implemented in a methodical manner, using test patients that you create, name, and run through the workflow process with varying visit types and medical scenarios.
Using a spreadsheet or database to capture and compare this analysis process is helpful, and can keep the project organized. Some scenarios to consider include:
- Are the templates for physical examinations age/sex appropriate?
- Are there opportunities to document all elements of the history of present illness (HPI)? The review of systems (ROS)?
- Are the examination templates set up to record based on 1997 or 1995 guidelines?
- Can your medical record be locked for security after a certain length of time? What is your addendum process?
- Can you import data such as lab results that are relevant to your current note? Is your note readable? Do consecutive notes appear to be copied, or cut and pasted?
- Do surgical/procedural templates allow for informed consent documentation?
- Is there space to document adverse effects or complications?
- Does your finger stick glucose lab template always default to a diabetes diagnosis? This should not be the case: Not everyone is diabetic!
- Does your wart destruction template allow for both benign and malignant lesion reporting?
Much of this developing and testing should be handled by your practice’s information technology (IT) department, but savvy coders, such as yourself, may want to develop super-user status. You can participate in pre-implementation activities, where you act as patients while the providers learn the software. During this time, make recommendations regarding coding compliance to the physicians, as well as the IT team.
EHR Software Works Best when Customized
The features that make an EHR easy to use, such as pre-filled templates, automatic code drop, and pre-determined diagnosis codes are the very things that cause compliance concerns. Think of the EHR as a tool that has to be sharpened and honed. It’s very effective if used correctly, but you have to learn how to use it safely, or you’re going to get hurt.
Most EHR software comes with pre-loaded E/M templates, which vendors probably will tell you are of the “plug and play” variety. Information systems experts and coders know that this is not necessarily the case. The Centers for Medicare & Medicaid Services (CMS) has not changed the E/M guidelines since 1997; however, the way the EHR captures data to support the levels of service has most definitely changed. Usually, the EHR configures the E/M templates in a manner similar to an audit tool, with a section for each of the key components: the chief complaint; HPI; ROS; past, family, and social history (PFSH); exam; and medical decision making (MDM). By working systematically, you and your IT staff can approach the development and customization of these templates in a way that ensures easy use and compliance within the final documentation.
Most EHR programs also have the capability to import documents. Scanning allows you to import a photo image of a document, to be stored in the patient’s chart. Establishing a direct interface between a lab or radiology department to import diagnostic results is a very efficient way to receive medical information into the patient chart. Having a consistent method of importing and cataloging these documents is important because it allows records to be easily identified and located at a later date. To meet compliance and patient care standards, all imported documentation must be reviewed and noted by the ordering physician before being stored in the electronic chart. Take it upon yourself to ensure that this is being done effectively and consistently.
Much of the custom work will be the IT department’s responsibility, with you acting as the compliance consultant. In smaller practice settings, your software vendor can be extremely helpful with the implementation process. Some EHR products offer users groups, which are online chat rooms offering a place for IT people, coders, and practice managers to post questions and discuss known issues. The bigger software companies provide seminars, conferences, and workshops on best-practice concepts and new initiatives. There is also an EHR discussion thread on the AAPC website where coders who are using the same EHR can “meet” and discuss.
Additional EHR Concerns to Address
Who Did What? Most EHRs have some “auditing” capability, where a behind-the-scenes look can identify which employee or clinician entered or edited which pieces of information. This allows you to see who is accessing the medical record (for instance, in case of privacy concerns), who is actually placing orders for medications and diagnostics, and where data entry errors might be occurring (to identify training opportunities). All EHRs should have signature and date recording ability for physicians and performing clinicians to meet the regulatory requirements of a legal medical record. This is one area where you can assist in workflow planning for compliance.
Procedure Templates: Most EHR software allows for easy documentation of office and surgical procedures. Templates should be designed to capture common elements of any given procedure, including anesthesia, informed consent, procedural elements, and follow-up instructions. When using these templates in a test environment, make sure the resulting procedure note makes sense, and your software default choices match the procedure that actually took place. For example, if your provider performs and documents a lesion excision, make sure your resulting note doesn’t document lesion destruction.
Annual Updates: Many of the EHR’s data lists, such as CPT® and ICD-9 codes, can be updated annually by the vendor, but often the vendor can provide only new codes. Frequently, the deleted and revised codes have to be edited individually and manually by you, or someone in IT, to ensure providers do not select invalid or deleted codes. One common issue in an EHR is that old diagnosis codes that are related to previous encounters remain in the patient’s list of chronic conditions, so the invalid codes can inadvertently be chosen again and again to appear on a claim form. Claim edits should be set up to prevent this from happening.
As you move forward with your implementation, other issues may present themselves. It’s critical for documentation compliance that you perform concurrent audits to review the EHR for completeness and accuracy as codes change, software is upgraded, and new providers begin to use the EHR. Having a comprehensive plan for EHR implementation that includes your participation in creating compliant EHR templates is essential. This implementation must include a comprehensive workflow evaluation to ensure that the EHR system your practice is using is configured in the best possible format as a legal medical record.
Pam Brooks, CPC, PCS, is physician services coding supervisor with Wentworth-Douglass Hospital in Dover, N.H.
April 4th, 2013
By Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS
As a physician auditor, I spend much of my time educating clinicians on proper documentation. This involves explaining and interpreting coding and compliance guidelines. When providing such guidance, the most common reply I hear from providers is, “I want it in writing.” An auditing compliance plan helps to satisfy this need.
Formulate a Plan
An auditing compliance plan gives providers written details of what is expected and/or permitted for documentation and billing purposes. For example, a plan may specify what terminology is permissible, which examination guidelines will be used, and the documentation required to support a type or level of service.
An effective plan also provides a map for all auditors (internal or external) to follow, and shows a practice’s “due diligence” in monitoring, education, and documentation. Finally, per the Office of Inspector General (OIG), auditing and monitoring of physician documentation is required.
Get It in Writing
The accompanying sample auditing compliance plan (pages 48-51) can aid in developing an effective plan of your own. Use this as a guide only; your auditing compliance plan should be based on your medical practice, Medicare/payer guidelines, and the recommendations of your compliance officer. I also recommended your practice’s health care attorney to review any compliance plan you put in place.
Put Your Plan into Motion
Formulating your auditing compliance plan is step one. You must also put the compliance plan into effect and ensure that it’s followed.
Auditing Compliance Plan Sample
A. Purpose of Audits
(Name of Medical Practice) promotes adherence to an Auditing Compliance Program as a major element in the performance evaluation of all Providers/Non-physician Practitioners (NPPs) documentation. Providers are bound to comply, in all official acts and duties, with all applicable laws, rules, regulations, standards of conduct, including, but not limited to laws, rules, regulations, and directives of the federal government and the state of ______________, Medicare Contractor, Fiscal Intermediary (FI), or Carrier (Name of MAC Provider) and rules policies and procedures of (Name of Medical Practice).
B. Orientation and Training
All new Physicians/NPPs will receive orientation and training in documentation and auditing policies and procedures. Failure to participate in required training may result in disciplinary actions, up to and including, termination of employment. Every Physician/NPP is asked to sign a statement certifying they have received, read, and understood the contents of the auditing compliance plan.
C. Education
Every Physician/NPP will receive periodic training updates in auditing. Ongoing education will be based on regulatory changes. Attendance is mandatory for all providers.
D. Audits/Monitoring
Auditors will conduct ongoing evaluations of compliance auditing processes involving thorough monitoring. The audits will inquire into compliance with specific rules, policies, documentation and policies of Medicare FIs or Carriers. Audits should identify any patterns and trends, non-compliance, or violations.
Auditors
All audits will be performed by Certified Coders with one or more of the following credentials; (CPC®, CPMA®, etc.). Auditors will be audited by external resources to monitor their accuracy and performance.
Frequency of Audits
Internal audits will consist of a minimum of 10 audits per Provider and will be conducted on a (monthly/quarterly/semi-annual/annual) basis. They will be selected on (random basis, trending reports, frequency).
Audit Error Rate
Error rates will be conducted with Provider audits and required to pass audits at a minimum of (90 percent is recommended).
Auditing Reports
Following each audit, Physicians will receive a written report, including:
- Patient name/date of service
- Provider name
- Level billed/level documentation supports
- Diagnosis codes billed/diagnosis documentation supports
- Any coding/billing discrepancies
- Medical necessity
- Recommendations/concerns
- Auditor name
E. Non-compliant Physicians/NPPs/Auditors
When disciplinary action is warranted, it should be prompt and imposed according to written standards of disciplinary action. Continuous violations will be reported and the Medical Director will determine the appropriate actions.
F. Documentation Requirements
New vs. Established Patients
Documentation should clearly state when the patient is new to the practice. A new patient is one that has not been seen within the same group practice in three years.
Component Requirements
These three components will be used to qualify the level of service performed. If any of the components is missing from the documentation, the services will not be billed.
- History
- Examination
- Medical decision making
Counseling/Coordination of Care/Time
- Documentation requirements:
- Time spent counseling, detailed documentation of counseling
- Coordination of care – documentation of time, detailed documentation of coordination of care provided, and conversations with other health care providers
Chief Complaint
The medical record should clearly reflect the chief complaint. The chief complaint will support the medical necessity of the services/procedures provided.
History
Three chronic illnesses can be used for an extended history of present illness (HPI).
HPI can be recorded by the ancillary staff or by the patient, but must be reviewed and confirmed by the provider.
Review of systems (ROS) and past medical, family, social history does not need to be re-recorded if obtained during an earlier encounter; however, documentation of no change, and that the information was reviewed, must be noted.
Documentation should clearly reflect the patient condition or circumstances that prevented the provider from obtaining any history.
Documentation of unremarkable and non-contributory are not acceptable forms of documentation.
Documentation of normal or negative is permissible, but abnormal findings must be described.
ROS must meet medical necessity of the systems reviewed.
“All others negative” (is or is not) acceptable with (your FI name).
If an element is used in the HPI, it cannot be used in the ROS.
Examination
All audits are based on 1995 or 1997 Documentation Guidelines for Evaluation and Management Services.
The extent of examination performed must meet medical necessity for the patient’s illness, condition, or injury.
Abnormal or any relevant negative findings should be documented and described. Negative, normal, unremarkable, and/or noncontributory are not acceptable forms of documentation.
Certain acronyms are not permissible. Each organ system or body area should be described in detail.
1995 Exam
The level of examination for 1995 guidelines will be determined as:
- 1 body area or 1 body system – Problem Focused
- 2-4 body areas and/or body systems – Expanded Problem Focused
- 5-7 body areas and/or body systems – Detailed
- 8 or more body systems – Comprehensive
Medical Decision Making (MDM)
No credit is given for a diagnosis that is not applicable to that day’s visit, unless it is a secondary issue.
Diagnoses must have relevance to the treatments provided or ordered.
Attending Physician should document when interpretation was done, and the results.
If history is obtained from someone other than the patient, this information must be documented.
When old records are reviewed, document that fact, along with a summary of those records.
Discussions with other health care providers must be documented, with a summary of the conversation.
Diagnosis Codes
Diagnosis codes for billing services, and ordering ancillary services, must be supported in the medical record.
Include information that will be important for ICD-10.
G. Other Evaluation and Management (E/M) Coding Guidelines
Critical Care (99291-99292)
Critical care must be supported by documentation. Time spent with the patient in critical care must be documented in the medical record. If the patient is unable to participate in discussions, time spent with family members or another decision maker must be documented.
Consultation Visits (non-Medicare Patients)
(99241–99255)
Consultations must be documented as a request for an opinion from another provider. It is the Provider’s responsibility to make sure a report is written to the referring Provider. The report must be documented. The documentation must state the reason for the consultation, as well as the Provider’s opinion and recommendation.
Observation Care Codes (8-hour Rules)
(99218–99226, 99234–99236)
Observation services that are less than 8 hours and performed on the same calendar day: Report 99218-99220 without discharge code 99217.
Observation care performed at a minimum of 8 hours, but less than 24 hours, on same calendar day: Report 99234-99236 without 99217.
Patients admitted to inpatient for less than 8 hours: Report 99221-99223 without discharge codes 99238-99239.
Prolonged Services (99354–99357)
Codes 99254-99357 must be used with other E/M codes.
Time spent with the patient must be face-to-face and documented in the medical record.
Each additional 30 minutes (minimum of 15 minutes) must be documented.
Documentation must support billed prolonged services.
Prolonged services without face-to-face services (99358-99359) are not billable.
Care Plan Oversight
Care plan oversight can be billed for patients in office/outpatient, hospital, home, nursing facility, hospice, home health agency, or domiciliary settings for non-face-to-face services.
Only one Physician can report care plan oversight per month.
Documentation must detail:
i. Patient name, date of service
ii. Detail of services performed
iii. Time spent on non-face-to-face services
iv. Physician name
Preventive Medicine (99381-99397)
Office E/M (can or cannot) be charged during a preventive visit for any abnormality that is encountered.
A separate note for the abnormality must be documented to support the visit.
Any insignificant problem or abnormality is included in preventive care.
H. Procedure/Surgery Documentation
Procedures performed without an E/M component must be documented in detail with:
Date of surgery, patient name and date of birth, surgeons, anesthesiologist and type of anesthesia used, facility where services were performed, consents obtained, preoperative diagnosis/postoperative diagnosis, indications for the procedure, IV infusions, description and details of procedure, findings, complications and how they were resolved, diagnostic reports/pathology reports, intra-operative information, postoperative condition of patient, and signatures.
I. Cloning Documentation
Cloning is “cut-and-paste” documentation resulting in the medical record being worded exactly the same or similarly to previous entries or encounters. Cloning is not acceptable.
J. Medical Necessity
Auditors will take reasonable measures to ensure that claims for services for office encounters and all procedures performed are reasonable and necessary, given the patient’s condition. All documentation must meet the medical necessity and MDM of the level charged.
K. Addendums/Late Entries
Any corrections to the medical record, such as addendums or late entries, are acceptable within (days/weeks/months). Dates of addendums/late entries must be documented.
L. Acronyms
Below are the only acceptable acronyms used for (Name of Medical Practice):
(e.g., Acceptable:
1. HTN – Hypertension
2. COPD – Chronic Obstructive Pulmonary Disease
Unacceptable:
1. HEENT in examination)
M. Handwritten Notes
Handwritten notes (i.e., hospital encounters that are handwritten) will be reviewed by two separate auditors, if illegible. If either auditor is unable to decipher handwritten information, the documentation will be considered non-billable.
N. Modifiers
Modifier use will be audited according to frequency and proper use.
O. Advanced Beneficiary Notice
of Noncoverage (ABN)
ABNs must be presented to the patient before a service/procedure is performed to notify the patient that Medicare may not cover the service. The entire form must be completed and signed by patients, but only for those services that may not be paid by Medicare.
P. Unbundling of Services
Some services are bundled into services per National Correct Coding Initiative (NCCI) edits. These services will not be unbundled per the request of a Provider unless documentation or modifiers support the medical necessity. Some items—such as pulse oximetry and electrocardiograms—are routinely bundled into office visits and not billed separately.
Q. Global Days/Surgical Packages
Services included in global days and surgical packages cannot bill be separately.
R. Incident-to
NPP professional services can be billed as incident-to with the following guidelines.
New patients are not billed as incident-to.
Established patients with new problems are not billed as incident-to.
The Supervising Physicians must be present in the office and immediately available when billing incident-to.
S. Scribes
The record must be clear that the Physician has performed all components of the service. Documentation should include that the information was obtained by the scribe acting on behalf of the Physician, the scribe’s name, and the date. Documentation should include a statement that the information obtained by the scribe has been reviewed and verified by the Physician.
T. Signatures
All signatures should be original or electronic and legible. Stamped signatures are not allowed. Attestation statements may be required if signature requirements are not met.
U. Teaching Physician Guidelines
Provided office services will be determined by the combine documentation from the Resident and Teaching Physician. The Resident can document his or her services in the office and the Teaching Physician must also document his or her participation of the service rendered. If documentation is incomplete or invalid, the Teaching Physician must document as if services were performed in a non-teaching setting.
Most practices have a medical director or a physician who is a “cheerleader” and supports coders, auditors, and compliance standards. This is the person you want to have help you develop and implement your plan. If you have a physician’s support, you have won half the battle. Organize an auditing compliance committee to develop the plan, and meet regularly for follow-up, amendments, and disciplinary measures with non-compliant individuals. You cannot expect your physicians to follow all rules and regulations without proper training.
Melody S. Irvine, CPC, CPMA, CEMC, CFPC, CPC-I, CCS-P, CMRS, is owner of Career Coders, LLC, a medical billing and coding school in Colorado. She served as an officer on the AAPC National Advisory Board.
April 1st, 2013