EMR Documentation Challenges 2011 Handout...
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1/21/2011 1 Cindy C. Parman, CPC, CPC‐H Coding Strategies, Inc. www.codingstrategies.com The format and/or content of this presentation is copyright © 2011 by Coding Strategies, Inc. (CSI), Powder Springs, GA. (CSI), Powder Springs, GA. This handout was created to accompany a verbal presentation and may not have value in the absence of the complete presentation material. 2 Copyright 2011 CSI Introduction 1. Compliant E/M 2. Over Documenting 3. Corrections Copyright CSI 2011 4. Cloned Notes 5. Patient Involvement 6. Valid Record 7. Stolen Data Final Thoughts
Transcript of EMR Documentation Challenges 2011 Handout...
1/21/2011
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Cindy C. Parman, CPC, CPC‐HCoding Strategies, Inc.
www.codingstrategies.com
The format and/or content of this presentation is copyright © 2011 by Coding Strategies, Inc. (CSI), Powder Springs, GA. (CSI), Powder Springs, GA.
This handout was created to accompany a verbal presentation and may not have value in the absence of the complete presentation material.
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Introduction
1. Compliant E/M
2. Over Documenting
3. Corrections
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4. Cloned Notes
5. Patient Involvement
6. Valid Record
7. Stolen Data
Final Thoughts
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CERT
Illegible signatures/dates
Other errors
Missing documentation
Insufficient documentation
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CERT
Missing/ incomplete doc
Incorrect codes
Other errors
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Whether a manual or electronic health record is maintained, there is still a
d h h need to ensure that the information generated by the healthcare provider is accurate, timely and available when needed.
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Software systems may allow submission of non‐compliant or potentially fraudulent E/M claims
May document a higher level than medically necessary
May have shortcuts that create documents automaticallyy y
Could result in distorted workflow
Or questionable data integrity
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Coding Engines
May code visit level solely May code visit level solely based on history and examination
May fail to consider medical necessity
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All encounters may default to comprehensive history and examination
Regardless of chief complaint
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Or presenting problem
Or visit frequency
Identical vital signs
Identical diagnosis
EMRs cut physician‐patient time
Doctors don’t look patient in the eye
Decreased patient satisfaction? Decreased patient satisfaction?
Restructure exam room?
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A hospital EMR/electronic coding combination:
Recognizes when data is missing or invalid
Suggests correct data
Detects “coding errors” (non‐covered diagnoses)Detects coding errors (non covered diagnoses)
Suggests correct codes to ensure payment
Automatically “loads” charges for supplies
May double bill for these items
But, results in fewer rejections!
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If the electronic template selected does not conform with either the medical condition of the patient or the service provided by the physician, an inappropriate code will be generated Thus for physician practices code will be generated. Thus, for physician practices that utilize an electronic medical record, the review and monitoring program must include the ability to determine whether the template description of the service provided or medical condition of the patient as selected by the physician is accurate.
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Notes that should be focused may become voluminous and templated
Not a product of clinical thinking
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Distracts from providing care
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Physician may have to search through repetitious notes for a i l li h
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single line that documents a new medical condition.
“Normal” may have different meanings
Exploding notes
Verifying author
Patient‐completed documents
Informed consent
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Pattern of coding may change with implementation of EMR
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EMR documentation may not match codes
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96% of physicians concerned “about losing the unique patient story” with the transition to point‐and‐click (template driven) EHRs
94% said that including the physician narrative as part f th di l d i “i t t” “ of the medical record is “important” or “very
important”
Less than 10% of physician respondents were confident that the federal government’s health information technology and reimbursement standards will lead to higher quality patient records
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Don’t use pencil
Don’t use red pen
N bl k
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No blank spaces
No removed pages
No obliterated entries
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Never write over, or otherwise obliterate the erroneous passage.
Draw a single line through the incorrect entry, keeping the original data legible.
Sign and date the deletion and state the reason for the correction.
Document the correct information or reference its location in the medical record.
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Follow the same principles!
Track original entry, and
The correction, with the date, time and reason for the change.
Any corrected record submitted must make clear the specific change made, the date of the change and the identity of the individual making that entry.
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Supplies additional information that was omitted from
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the original entry.
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Used to provide data that was not available at the time of the original entry.
Should be timely
List reason for addition or clarification of information
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Late entries, addendums or corrections to a medical record are legitimate occurrences.
Bears the current date of entry
Signed by individual making entry
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How is the addendum or late entry “linked” to the original document?
Need to be certain that when original document is printed or accessed, the late entry or addendum is as well…
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Most EMR system designs fail to include
hprotections to ensure the correct use of “shortcuts.”
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October 4, 2010
But CMS and Medicare contractors are wary of classic EHR physician documentation shortcuts p y– cloning (cut and paste), macros and templates – and audits are bearing out their concerns.
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Default notes
Copy Forward
Copy & Paste
Make it Mine
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Typo will be repeated in every document…y
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Physicians copy information from previous patient encounters (e.g., demographic, history of present illness, exam, medical decision making) and paste it in the current encounter.
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Macros are a type of EHR shortcut that allows the entry of generous customized data quickly.
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Physicians can fill out templates for patient encounters or other services that cover a lot of ground with a few key of ground with a few key strokes.
The ROS may be pre‐filled with the term “negative” for each organ system.
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While CMS has not taken a position on templates, the agency has conveyed that h they are meant to prompt physician documentation, not do the lion’s share of it.
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Question: Our office uses a template for office visits. Does Medicare prefer one type of template to the others?
Answer: Medicare does not endorse any templates… In reviewing medical records, a pattern of template use sometimes has a “cloning” effect between patients. The patients’ medical records tend to lose the patient‐specific information. When using a template for documentation, take care to note your findings in a patient‐specific manner.
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When designing a template for your practice, beware of the following pitfalls:
Templates can limit providers’ ability to enter free text information
Templates can encourage physicians to document more services than they rendered
Users might inappropriately interpret the template
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5. The PSC and the ZPIC shall determine if patterns and/or trends exist in the medical record which may indicate potential fraud, waste or abuse. Examples i l d b t t li it d tinclude, but are not limited to:
The medical records tend to have obvious or nearly identical documentation;…
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Encounter records can be created in advance
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Even if patient did not show up
Would the physician have dictated the information?
If not, is it medically ynecessary?
If not relevant, has it only been added to increase the level of service?
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Some information was taken from billing records
Billing codes easier to link
Standard definitions
Some medical data was historical, but listed as current conditions
Reflected codes “required” by insurers
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Insurance data, by contrast, is already computerized and far easier and cheaper to download.
But it is also prone to inaccuracies, partly because of p , p ythe clunky diagnostic coding language used for medical billing, or because doctors sometimes label a test with the disease they hope to rule out…
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Patients who discover mistakes in their health f d linformation can delete
information, add notes or ask providers to correct inaccuracies!
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That may mean that the healthcare provider has to correct diagnosis
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to correct diagnosis codes on insurance claims?
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Most current EMRs do not have any responsibility for documentation and coding compliance
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compliance.
By contract
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The documentation must constitute a valid medical record in all its attributes.
Follow established rules for medical records.
Currently EMRs are: Currently EMRs are:
Not standardized
Minimally certified
May decrease data quality
May increase fraud
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Physician orders and/or CMNs
Patient questionnaires (ROS, PFSH)
Progress notes of all providersg p
Treatment logs
Patient visit reports
Procedure, lab, imaging and diagnostic reports
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Integrity of clinical documentation recorded
Variability in records management
Usability and quality of clinical care guided by the electronic recordelectronic record
Variability in system access
Variability in auditing or quality assurance
Perceived lack of malpractice protection
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The patient’s medical record is considered incomplete ith t th ti ti th t without authentication that
the information is a true and accurate representation of the services provided.
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Have a password log‐on requirement which irrefutably identifies the author of every entry.
Authorship vs. countersigning…p g g
No “auto‐authentication”
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Non‐repudiation – assurance that the signer cannot deny signing the document in the future
User authentication – verification of the signer’s gidentity at the time the signature was generated
Message integrity – certainty that the document has not been altered since it was signed
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All individuals entering or reviewing information in the medical record may require an electronic signature.
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Locum tenens
Students
Scribes
Auditors
Once an organization is party to litigation, it has a duty to preserve evidence.
In the old days, the paper chart was locked in a filing cabinet.
Digital information is readily accessible and easily changed.
However, electronic information, including EMRs, must be preserved and not altered.
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Patient data may include:
EMR information
Queries
Emails
Spreadsheets
External hard drives
Back‐up files
Organizations must be able to search all systems to retrieve records related to a subpoena.
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May have to create a segregated database to ensure proper protection of records
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of records.
Difficult at best…
May require the purchase of separate software tools!
May have to demonstrate to the court that the tool works…
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For these reasons, it is nearly impossible for electronic records to reproduce exactly what the physician saw on his what the physician saw on his or her screen at the time of an incident – especially one that occurred years ago…
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February 26, 2010
38 entities reported a breach affecting 500 or more individuals
Hospitals
Insurers
Physician practices
Due to: Due to:
Theft of computer, portable device, paper records, films, EMRs
Loss of backup tapes, portable electronic device, laptop
Hacking
Incorrect mailing of postcards, unauthorized access mailings
Misdirected email or phishing scam
Unauthorized access to computers or EMRs
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80% of healthcare organizations surveyed had experienced at least one incident of lost or stolen electronic health information in the past year
4% had more than 5 patient data breaches
The average cost of a data breach exceeded $210 per compromised record
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There needs to be a policy on printing documents.
Copies that are printed p pshould be tracked by an audit trail to identify users who have printed reports from the system.
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amednews.com , January 17, 2011
EMR may not be designed to work with specialty
Work flow problems
Systems provided to physicians by hospitalsSystems provided to physicians by hospitals
Could cause productivity to fall 10% first year
Monetary loss of approximately $120,000
No system will be an exact match
Only after becoming a user can the physician apply the EMR tool…
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EMRs complicate the ROI process…
Multiple databases
P i l i Privacy regulations
State regulations
3rd Party requests
HIM policies
Outsource?
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EMRs will be easier to audit than requesting paper
The payors will just access the electronic records directly
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Questions?
