Electronic Health Records - Advantages and Pitfalls of Documentation

Electronic Health Records - Advantages and Pitfalls of Documentation Kansas City, KS HCCA Regional Conference September 25, 2015 1:00 P.M. 2:00 P.M. Presented by: Cynthia A. Swanson, RN, CPC, CEMC, CHC, CPMA AAPC ICD-10-CM Proficient Senior Manager Healthcare Consulting Seim Johnson, LLP 18081 Burt Street, Suite 200 Omaha, NE 68022 Tel: 402.330.2660 Fax: 402.330.5108 cswanson@seimjohnson.com 2 1

Disclaimer A presentation can neither promise nor provide a complete review of the myriad of facts, issues, concerns and considerations that impact upon a particular topic. This presentation is general in scope, seeks to provide relevant background, and hopes to assist in the identification of pertinent issues and concerns. The information set forth in this outline is not intended to be, nor shall it be construed or relied upon, as legal advice. Recipients of this information are encouraged to contact their legal counsel for advice and direction on specific matters of concern to them. The information contained in this document is current at the time of preparation. For ongoing coding revisions and Medicare updates, refer to AMA publications, your local Medicare contractor and CMS notices. CPT is a registered trademark of the American Medical Association. All rights reserved. 3 Agenda Paper Chart to Electronic Health Record (EHR) Advantages and Pitfalls EHR Documentation Contradictions/Concerns Medicare Signature Requirements Practice Tips and References for: Medicare shared/split services Medical students, residents and teaching physician (TP) services Scribe services Prevention and Coding Compliance Questions/Discussion 4 2

Paper Chart to EHR Strengths/Advantages Legibility Easeof Search Information Granularity Misfilings Lost Charts Scheduling Billing Interface/Orders Weaknesses/Pitfalls Learning Curve (slower) Security Costs Upgradesand Depreciation 5 EHR Capabilities/Other Considerations E-prescribing Reduced testing, reduced medication errors, reduce waste and duplicate testing Shared record Templates Data extraction Software selected codes Automated inclusion of diagnosis information 6 3

EHR Capabilities/Other Considerations (continued) Automated reminders Preventive care Data for research Audit Legal defense Meaningful use - $ if using, $ if not using Hospitals Physicians 7 EHR - Code Selection/Documentation Billing Software Features Charge capture Evaluation and Management (E/M) code level assignments Who makes CPT/HCPCS code determination(s) in your organization? Documentation and election of other services Procedures Laboratory Tests (and venipunctures) Diagnostic Tests Injections/Medications 8 4

EHR -Auto Coding Auto Coding E/M Services CPT codes 99201-99499 May be inaccurate May not follow AMA, CMS and/or Medicare Administrative Contactor (MAC) guidelines Does the physician free text? (not part of E/M calculation) Is all documentation flowing through to a printed page? Must understand your EHR and exactly how it determines the level for E/M codes if utilizing EHR functionality of auto-coding 9 EHR - Pitfalls Missing or Incomplete Documentation All documentation elements for the E/M visit are not provided for review Elements are documented on templates however do not print on the output documents or are found on separate documents Physician may refer to another document or flow sheet in the note Practitioners may neglect to generate additional notes Some EHR systems have separate notes for procedures and other types of services» The practitioner may neglect to generate and sign off on these notes 10 5

EHR - Pitfalls (continued) Copy and Paste Features and Cloning *How does the EHR appear to an outside reviewer? Copy forward -History, Review of Systems (ROS), Past, Family and Social History (PFSH) elements that may not be pertinent to the visit Many EHRs allow practitioners to bring forward a previous exam in addition to the assessment and plan Copy and paste features can lead to cloned notes and potential overbilling 11 EHR - Pitfalls (continued) Over-Documentation Over-documented ROS and exam elements solely to meet the requirements for a higher level of service when the nature of the presenting problem suggests a lower level Templates should be built based on the presenting problem and when built correctly they will only have the pertinent ROS and exam elements standard for the presenting problem Medical Necessity and Volume of Documentation Are multiple pages of EHR notes really necessary for a minor complaint or a stable diagnosis? Education with practitioners 12 6

Medical Necessity Medicare Claims Processing Manual, Chapter 12, 30.6.1 Medical necessity of a service is the overarching criterion for paymentin addition to the individual requirements of a CPT code.it would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted.the volume of documentation should not be the primary influence upon which a specific level of service is billed. Documentation should support the level of service reported. The service should be documented during, or as soon as practicable after it is provided in order to maintain an accurate medical record. 13 Documentation Contradictions/Concerns Example of Questionable Notes Date of Service: 02/13/2015 Date of Birth: 05/06/1950 HPI: This 48 year old male is seen today for complaints of fever, runny nose, sore throat and cough for the past five days. Taking OTC medication although he does not believe it is helping. He also has right ankle pain due to missing the last step coming out of his apartment and falling two days ago, severity of pain 4/10. Exam: HEENT:normal, Lungs:normal, Heart:RSR, Musculoskeletal: normal and Skin: normal Diagnosis: URI, rt. ankle sprain Plan: Orders -CBC, Rt. ankle x-ray and RX antibiotic x 10 days Dictated by xxxxx, MD: 05/30/2015 14 7

Medicare Signature Requirements Medicare Program Integrity Manual, Chapter 3, 3.3.2.4 Signature Requirements For medial review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable. 15 EHR -Medicare Signature Requirements Signature Authentication WPS Medicare has a statement regarding electronic signatures: For providers using EMR systems, it is crucial that the electronic signature is affixed to the records when corresponding to all Medicare requests for documentation. Although CMS has not published formal regulations regarding electronic signatures, we recommend that an electronic signature be accompanied by a statement indicating that the signature was applied electronically. We also recommend including the date and time the record was authenticated. Electronic signature notations can include the following (not all-inclusive): Electronically signed by Verified by Reviewed by Signed by Authenticated by Authorized by Confirmed by Finalized by Electronically approved by 16 8

EHR - Medicare Signature Requirement Pitfalls Pitfalls: -The electronic signature statement on the document does not meet Medicare requirements or is non-existent -The physician electronic signature is signed and dated long after the service was provided and billed Example: Date of service: 12/06/2013. Electronic physician signature 01/22/2015. DO: Maintain current signature logs -Change of staff, new, retired, termed employment, etc. Utilize signature attestation statement when necessary 17 EHR -Authentication by Author Who Did What? Pitfalls: Authentication of nursing and other ancillary staff is missing This can be troublesome when you consider there are only certain parts of E/M documentation that ancillary staff can actually perform Not all systems show the authentication of the author within the note When the note prints, the RN could have documented the entire visit, yet all you see is the practitioner s electronic signature Caution: Inability of a practitioner to use ancillary staff to record the History of Present Illness (HPI) of an E/M encounter Systems have audit logs that track who did it in the metadata 18 9

EHR - Templates Medicare Program Integrity Manual, Chapter 3, 3.3.2.1.1 - Progress Notes and Templates A. Definitions For the purposes of Section 3.3.2.1.1, the following definitions apply: 1. "Progress Notes" --visit notes, encounter notes, Evaluation and Management documentation, office notes, face-to-face evaluation notes or any other type of record of the services provided by a physician or other licensed/certified medical professional (LCMP) in the medical record. Progress notes may be in any form or format, hardcopy or electronic. 19 EHR - Templates (continued) 2. "Template" -a tool/instrument/interface that assists in documenting a progress note. Templates may be paper or electronic. Electronic records may involve any type of interface including but not limited to: -simple electronic documents, -sophisticated graphical user interfaces (GUIs) with clinical decision and documentation support prompts, or -electronic pen capture devices. 20 10

EHR - Templates (continued) B. Guidelines Regarding Which Documents Review Contractors Will Consider The review contractor shall consider all medical record entries made by physicians and Licensed/Certified Medical Professional (LCMPs). See PIM 3.3.2.5 regarding consideration of Amendments, Corrections and Delayed Entries in Medical Documentation The amount of necessary clinical information needed to demonstrate that all coverage and coding requirements are met will vary depending on the item/service See the applicable National and Local Coverage Determination for further details 21 EHR - Templates (continued) 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 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. 22 11

EHR - Templates (continued) Physicians/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. 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. 23 EHR - Shared/Split E/M Services Shared/Split E/M Services Who did what? Does documentation support Medicare s shared/split service rules? Medicare Claims Processing Manual, Chapter 12, 30.6.1 Office/Clinic Setting When an E/M service is a shared/split encounter between a physician and a non-physician practitioner (NP, PA, CNS or CNM), the service is considered to have been performed incident to if the requirements for incident to are met and the patient is an establishedpatient. If incident to requirements are not met for the shared/split E/M service, the service must be billed under the NPP s UPIN/PIN, and payment will be made at the appropriate physician fee schedule payment. 24 12

EHR - Medicare Teaching Physician Rules Medical Students, Residents and Teaching Physician (TP) Services Who did what? Does the medical record documentation meet Medicare s Teaching Physician (TP) documentation guidelines? Medicare Claims Processing Manual, Chapter 12, 100 25 EHR - Medicare Teaching Physician Rules (continued) Documentation -Notes recorded in the patient's medical records by a resident, and/or teaching physician or others as outlined in the specific situations below regarding the service furnished. Documentation may be dictated and typed or handwritten, or computer-generated and typed or handwritten. Documentation must be dated and include a legible signature or identity. Pursuant to 42 CFR 415.172 (b), documentation must identify, at a minimum, the service furnished, the participation of the teaching physician in providing the service, and whether the teaching physician was physically present. In the context of an electronic medical record, the term 'macro' means a command in a computer or dictation application that automatically generates predetermined text that is not edited by the user. 26 13

EHR - Medicare Teaching Physician Rules (continued) When using an electronic medical record, it is acceptable for the teaching physician to use a macro as the required personal documentation if the teaching physician adds it personally in a secured (password protected) system. In addition to the teaching physician s macro, either the resident or the teaching physician must provide customized information that is sufficient to support a medical necessity determination. The note in the electronic medical record must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if both the resident and the teaching physician use macros only. 27 EHR - Scribe Services Scribe Services (Mobile Transcriptionist for the Practitioner) Impact to EHR and appropriate physician attestations WPS -Guidelines for the Use of Scribes in Medical Record Documentation "Scribe" situations are those in which the physician utilizes the services of his, or her, staff to document work performed by that physician, in either an office or a facility setting. In Evaluation and Management (E/M) services, surgical, and other such encounters, the "scribe" does not act independently, but simply documents the physician's dictation and/or activities during the visit. The physician who receives the payment for the services is expected to be the person delivering the services and creating the record, which is simply "scribed" by another person. 28 14

OIG Comments/Concerns -E/M Services OIG Work Plan 2012 Addresses: Evaluation and Management Services: Potentially Inappropriate Payments OIG will assess the extent to which CMS made potentially inappropriate payments for E/M services and the consistency of E/M medical review determinations Review multiple E/M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments Medicare contractors have noted an increased frequency of medical records with identical documentation across services Medicare requires providers to select the code for the service based upon the content of the service and have documentation to support the level of service reported OIG Work Plan 2013 E/M Services OIG Work Plan 2014 E/M Services 29 OIG References Related to E/M services May 2012 OEI-04-10-00180 Coding Trends of Medicare Evaluation and Management Services May 2014 OEI-04-10-00181 Improper Payments for Evaluation and Management Services Cost Medicare Billions in 2010 30 15

EHR - Other Considerations for Compliance EHR decision makers -who is sitting at the table in your organization? Appropriateness of E/M codes and levels Medical necessity and appropriate medical record documentation for all services billed Medical abbreviations list Consider Medicare incident-to rules Consider Medicare guidelines for the supervision of diagnostic tests 31 Ongoing and Effective Compliance Program OIG recommends to be effective, both the coding compliance program and the corporate compliance programs should be continually assessed and monitored Effectiveness of program is the measurement of various outcome indicators May include billing and coding error rates, audit results, overpayments and underpayments Crucial activity that examines the underlying structure, process and outcomes of the program 32 16

Ongoing and Effective Compliance Program (continued) Coding Compliance Department Code of Conduct Organization of department and qualifications of staff Sufficient resources, training, authority to carry out mission Relationship between departments Regular reporting of audit results Necessary and ongoing educationis performed to address compliance issues Prevention Auditing and monitoring have improved results and/or processes 33 Wrap-Up Questions/Discussion 34 17