Image Credit: ILLUSTRATION/PAUL JUESTRICH; PHOTOs shutterstock.com
The electronic health record (EHR) has many benefits:
- Improved patient care;
- Improved care coordination;
- Improved diagnostics and patient outcomes;
- Increased patient participation; and
- Increased practice efficiencies and cost savings.1
EHRs also introduce risks, however. Heightened concern about EHR misuse and vulnerability elevates the level of scrutiny placed on provider documentation as it relates to billing and coding. Without clear guidelines from the Centers for Medicare and Medicaid Services (CMS) or other payers, the potential for unintentional misapplication exists. Auditor misinterpretation is also possible. Providers should utilize simple defensive documentation principles to support their services and minimize their risks.
Reason for Encounter
Under section 1862 (a)(1)(A) of the Social Security Act, the Medicare Program may only pay for items and services that are “reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member,” unless there is another statutory authorization for payment (e.g. colorectal cancer screening).2
A payer can determine if a service is “reasonable and necessary” based on the service indication. The reason for the patient encounter, otherwise known as the chief complaint, must be evident. This can be a symptom, problem, condition, diagnosis, physician-recommended return, or another factor that necessitates the encounter.1 It cannot be inferred and must be clearly stated in the documentation. Without it, a payer may question the medical necessity of the service, especially if it involves hospital-based services in the course of which multiple specialists will see the patient on any given date. Payers are likely to deny services that cannot be easily differentiated (e.g. “no c/o”). Furthermore, payers can deny concurrent care services for the following reasons:3
- Services exceed normal frequency or duration for a given condition without documented circumstances requiring additional care; or
- Services by one physician duplicate/overlap those of the other provider without any recognizable distinction.
Providers should be specific in identifying the encounter reason, as in the following examples: “Patient seen for shortness of breath” or “Patient with COPD, feeling improved with 3L O2 NC.”
Assessment and Plan
Accurately representing patient complexity for every visit throughout the hospitalization presents its challenges. Although the problem list may not dramatically change day to day, providers must formulate an assessment of the patient’s condition with a corresponding plan of care for each encounter. Documenting problems without a corresponding plan of care does not substantiate physician participation in the management of that problem. Providing a brief, generalized comment (e.g. “DM, CKD, CHF: Continue current treatment plan”) minimizes the complexity and effort put forth in the encounter and could result in auditor downgrading upon documentation review.
Developing shortcuts might falsely minimize the provider’s documentation burden. An electronic documentation system might make it possible to copy previous progress notes into the current encounter to save time; however, the previously entered information could include elements that do not require reassessment during a subsequent encounter or contain information about conditions that are being managed concurrently by another specialist (e.g. CKD being managed by the nephrologist). Leaving the copied information unmodified may not accurately reflect the patient’s current condition or the care provided by the hospitalist during the current encounter. Information that is pulled forward or copied and pasted from a previous entry should be modified to demonstrate updated content and nonoverlapping care relevant to that date.
According to the Office of Inspector General (OIG), “inappropriate copy-pasting could facilitate attempts to inflate claims and duplicate or create fraudulent claims.”4
An equally problematic EHR function involves “overdocumentation,” the practice of inserting false or irrelevant documentation to create the appearance of support for billing higher level services.4 EHR technology has the ability to auto-populate fields using templates built into the system or generate extensive documentation on the basis of a single click. The OIG cautions providers to use these features carefully, because they can produce information suggesting the practitioner performed more comprehensive services than were actually rendered.4