In our review of hundreds of charts from multiple EHR systems, several frequently made errors emerged, and for this article, we will discuss seven common mistakes end how to avoid them.
Over the years, we have always stressed the importance of clear, accurate, and error-free coding. An important step toward achieving this is accurate usage of your EHR system. In our review of hundreds of charts* from multiple EHR systems, several frequently made errors emerged, and for this article, we will discuss seven common mistakes and how to avoid them.
Some of the issues may apply to you and your EHR documentation, while others will not. As the old saying goes, “If the shoe fits, wear it.”
Coding based on the EHR calculator. Relying on the calculator to pick the correct code is dangerous in two ways. First, the calculator may be inaccurate, only partially correct, or may use rules that recommend a code that is too high or too low due to simplified computer logic. For example, we have recommended for years that you use the 1995 guidelines, especially for physical examination. Some EHR calculators are based solely on 1997 guidelines. In addition, many of the calculators do not give you credit for updating the review of systems (ROS) and past, family, and social history (PFSH), which many of you have found is the most efficient and effective way of capturing those elements required for a return visit.
Second, you may not be using the EHR as the manufacturer intended or set the programming around. If the data are not in the exact correct location, the calculator will not recognize the data points. For example, if you bring forward the chief complaint from previous visits but do not address the issue in that encounter, the calculator may incorrectly count the problem as an additional problem addressed. Other programs will allow you to remove elements or modify the template but do not then take into account the changes you have made when the calculator is employed.
Copying the chief complaint and History of Present Illness (HPI) from the previous encounter to start your documentation for the current visit.
Not only is this confusing from a clinical standpoint in understanding the reason for the visit that day, but it is equally confusing from an auditing standpoint. Should you get credit for providing the work that day if the wording is identical to what you documented the last visit or the two visits before? This problem could be easily remedied by creating a new chief complaint and HPI for each visit and placing the older HPI and chief complaint information where it belongs-in past history or ROS. The Documentation Guidelines are very clear: Chief complaint and HPI must be created for each visit.
Failure to document the reason for ordering a test. Many templates allow you to document that you ordered a test but do not make it easy for you to document the reason why the test is ordered. As more and more importance is placed on “medical necessity,” it becomes increasingly important to document your thinking as to why you’re ordering that test that day. Additionally, each test will require the correct diagnosis for the testing entity to be paid for the service.
Incorrect reasons for the test are a significant burden for many groups, resulting in denials and subsequent appeals for tests done in your office or phone calls and faxes to and from other entities that provide your patients with tests. Be sure to document the reason for the test next to the test or in another consistent location. Some templates will allow you to create prompts next to the tests commonly ordered with commonly used diagnosis codes or descriptions capturing the reason for each test that you order.
Copying ROS and PFSH. If the documentation is identical in the review of systems and past, family, and/or wocial history, except for a few changes, the question is, did you recapture all of that information that day? Or, did your staff ask the patient whether there were any changes and just add the changes? You are being paid for the work you do that day, not what was done at the last visit. This problem can be easily remedied by adding a new template with the statement “ROS & PFSH were reviewed from the last visit (enter exact date), and there are no changes except__________ or changes as noted as follows.” Have your staff ask the questions and fill in the blanks.
Incorrect diagnosis. This is one problem that has actually improved with the use of the EHR for many encounters. However, we continue to see the same diagnosis being used for a problem that was addressed at the last visit instead of updating to the diagnosis for the problem being addressed that day. In addition, the diagnosis for the test or other service being ordered, or performed, may be different from the reason for the evaluation and management encounter and yet the EHR note assigns the same diagnosis code(s) in the same order to every code reported on the visit. Each diagnosis should be accurately captured and tied to the correct CPT/Healthcare Common Procedure Coding System code, and codes not addressed or present that day should not be reported. Additionally, any symptoms that have been tied to a disease process that is reported or that have resolved during treatment must be actively removed from the active problem list so they are not reported on the claim.
Medical Decision-Making not documented clearly or not counted correctly. Some EHR templates do not allow you to clearly document your assessment and/or plan for that patient visit. A few common problem areas in Medical Decision-Making documentation include:
All of these documentation pitfalls, while not fatal in an audit, can often result in increased explanation, defense, denial, and additional chart review. The more complete the record and the more obvious the reason and understanding for the code selected, the more likely you are to be paid and avoid future chart reviews.
Medical records that no one else can understand. The use of the EHR bent to meet the needs of the user often sees the placement of critical data in different parts of the record within the same practice. All of us have seen and many have heard the complaints of the EHR burying the truly clinically important data in a deluge of “BS” that was added to meet the documentation requirements.
Most EHRs allow for templates to collect the relevant data and package it in the form of a letter or shortened note to pass to others. Consistency is key in the regard. Once you have a system that works and is properly set up, make sure everyone in the practice is following the same format to create a coherent and usable record.
In the end, it is not the system but the operator destined to take the fall for any mistakes in documentation and/or coding while using an EHR. Your understanding of the rules and the development of protocols within your practice to create a complete and accurate record using clear and accurate templates can solve these problems.
The focus on accurate use of the EHR should be considered for support of billing today and, as you have heard us say many times, as a data repository for tomorrow. As we move forward to new and more complex payment systems based on quality and outcomes, the groups that have consistent data will be better positioned for the next generation of health care regardless of the final shape.
*Note: Some charts were reviewed under lawyer-client privilege, as we work with lawyers to try to prevent physicians from being convicted of fraud or paying large fines or repayments for poorly documented or “incorrectly coded” services. The majority of charts were reviewed under contract with different practices to add an outside opinion of the accuracy and completeness of their documentation and billing, some through their compliance plans.
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