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8/1/2011
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EMRs and Audit
Issues
Presented by:
Melody S. Irvine
CPC, CPMA, CEMC, CPC-I, CCS-P, CMRS
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Agenda
• Difference between EMR and EHR?
• Common problems encountered through
audits
– Cloning
– Templates
– Medical Necessity
• How has it affected our physicians and
patients?
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All Systems are Different
• How is system configured and set-up?
• Be aware of what areas that could be potential
problems or concerns for your practice
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Auditing Concerns with EMR
• Cut and paste/cloning/canned statements
• Diagnosis
• Buzz words/terminology
• Ancillary orders
• Chronic illnesses
• Grey areas of auditing
• Medical necessity
• Electronic signatures
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Difference Between EHR and EMR
• EMR verses EHR
– EMR (Electronic Medical Record)• Patient information relevant to encounter
– EHR (Electronic Health Record)• Data from all other sources
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Risk of Audits with EMR
• EMRs may increase your risk of an audit—
unless you use the system‘s documentation
features properly.
• EMR notes should essentially mirror handwritten
documentation.
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Cloning
• Number one risk is for fraud/abuse
• Definition of cloning
• Why kind of problems is cloning causing?
– Identical notes
– Conflicting information
– Could represent more than what was actually
performed during encounter
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Cloning Problems
• Example of problems with copy and paste:
• Documentation states:
• ―Sutures healing well‖
– Reality:
• The patient had sutures 1 year ago
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Potential Risks of Cloning
• Documentation that is verbatim and obviously
cut and pasted would not stand up in a court of
law
• Permission from original author of note
• Credibility
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Why Do They Clone?
• Selling point
– Ease of documentation
• Saves time and is convenient
– Downfalls:
• Risk of fraud/abuse
• Could compromise patient care
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What to Do?
• The provider should read over any cloned
documentation
• Monitor cloning and documentation
– Auditor
– Healthcare provider
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What Does the OIG Say?
• 2011 Work Plan
• OIG states:
―Medicare contractors have noted an increased
frequency of medical records with identical
documentation across services”
• Other payers will follow the same guidelines
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Canned Templates
• Try to avoid "canned" templates
• Don‘t always point out pertinent positives
• Referring physicians don‘t feel the
documentation is complete
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Diagnosis
• Diagnosis
• Code Searches
– Example: Diabetes with manifestations
• Key words to find diagnosis codes
• Using unspecified codes
• Alphabetizing the list of diagnosis codes
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Buzz Words
• Buzz words
• Computer doesn‘t recognize words
• Documented something that didn‘t happen
during the patient visit
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Testing
• Ordering lab tests through EMR and charging
for it instead of ordering
• Reading of lab tests by personnel other than
physician
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Chronic Problems
• Chronic problems counted
• Chronic problems not addressed or pertinent to
visit/diagnosis
• Will EMR count a chronic problem?
– Diabetes and ulcer?
– Sinusitis and chronic lumbar back pain?
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Grey Areas
• How are grey areas addressed?
• Possible grey areas
– Unacceptable terminology
– All others negative
– HPI
– Positive responses from patients
– ‗95 examination guidelines
– HEENT
– Examination not set up for certain age groups
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History
Per CMS Guidelines for 95/97
A ROS and/or a PFSH obtained during an earlier
encounter does not need to be re-recorded if there is
evidence that the physician reviewed and updated the
previous information. This may occur when a
physician updates his or her own record or in an
institutional setting or group practice where many
physicians use a common record.
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History
• DG:– The review and update may be documented
by:
describing any new ROS and/or PFSH
information or noting there has been no
change in the information; and noting the date
and location of the earlier ROS and/or PFSH
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History
• DG:
The ROS and/or PFSH may be recorded by
ancillary staff or on a form completed by the
patient. To document that that physician
reviewed the information, there must be a
notation supplementing or confirming the
information recorded by others.
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History
• In a nutshell
– Ancillary staff can document ROS/PFSH
– Doctor must confirm reviewing information of
ROS/PFSH
– Only doctor can document HPI
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Medical Necessity
What is the definition of Medical Necessity? CMS - “services or items reasonable and necessary
for the diagnosis or treatment of illness or injury or to
improve the functioning of a malformed body
member”
CMS related to E/M services - “medical necessity
related to the presenting problem should be the
overarching factor in determining the level of service
billed”
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Medical Necessity
• EMR problems with medical necessity
– High level of service for minor problems
– EMR cannot decipher medical necessity
– Comprehensive History and Exam with low Medical
Decision Making
• EMR set up to decipher 2 out of 3 components
not medical necessity
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EMR Choosing Level of Service
• EMR choosing level of service
– Giving them a higher level than necessary
– May be able to turn this feature off
• Over document in templates
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Tracking of Individuals
• Tracking in and out of providers – right
person is logged in for document
• Not changing from medical assistants
(MA)/nursing entering information to
doctor
• Doctors giving out passwords to
MA/nurses
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Electronic Signatures
• Sign each note and must be legible
• You could end up under the microscope for an
audit
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Electronic Signatures
• CMS states ―providers need a system and
software products which are protected against
modification, etc., and should apply
administrative procedures which are adequate
and correspond to recognized standards and
laws.”
• Potential for misuse or abuse with alternate
signature methods
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Electronic Signatures
Some systems lock out providers after so many
days and they are unable sign in after a certain
amount of time
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Details of Procedures
• Detail of procedures performed
– Example: joint injections
• MG, mL, etc. programmed correctly
• Number of units given
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Terminology
• Templated terminology
– Free text
– Acronyms
– Reviewed by auditors
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Interfaced with Billing?
• Interface correctly with billing EMR.
– Are charges crossing over appropriately
– Edits to catch problems or fix problems
• Use a dummy code for coders to follow
through
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Automatic Log Off
• Automatic log off time if no entries have
been made
• Signing out when not at your desk
• Again, password security
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Auditing Compliance Plan
• I recommend an Auditing Compliance Plan
• Support the grey areas of auditing
• Examples: – ‗95 examination
• Expanded problem focused and detailed
– Which guidelines do you use? 95/97?
– Any grey area that could be contested
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Compliance Issues
• Scrambling to set up EHR systems and not
taking the time to worry about compliance of
EHR systems
– Physical Security
– User Security
– System Security
– Network Security
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Implementing EMR System
• Auditors should be involved
• Find a system that supports all the needs of your
practice
• Understanding your need is critical to narrow
down the choices of your EMR system
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Implementing EMR System
• Other considerations:– Number of user licenses required
– Compatibility with your operating system
– Training of staff
– Technical support
– Protection of confidentiality
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Steps to Implementation
• Create a comprehensive project plan
• Build a team with the right people
• How will the system be used
• Time constraints
• Verify compliance
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Steps to Implementation
• Put your computer server in a secure
room, locked;
• Use an EMR with user management and
permissions;
• Make regular back-ups and store them in
a secure place; and
• Employ a computer specialist.
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Selling Factors
• Saves time
• Cut and paste is also a selling factor
• This software can do everything
– Identify what you need
– Identify and ask questions about some of
those problems we have identified
• Easy to learn
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Physician PROS and CONS
with EMR
• CONS
– Systems can be difficult to learn
– Time it takes to enter information
– Computer down time
– Engage less with patients leading to loss of
the human touch
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Physician PROS and CONS
with EMR
• PROS– Easier to monitor for medication use, patient
compliance, changing symptoms, immunizations,
recall notices, automatic reminders and alerts, and
other factors
– Quick access to other offices and hospitals
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Physician Complaints with EMR
• Systems fail to recognize word due to
misspellings
• Takes more time to click through screens than
use a pen and paper to order tests
• Difficulty in finding important information
• Having a personal face-to-face patient/physician
relationship
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Physician Complaints with EMR
• Some systems can be tedious in completion of
prescriptions, etc.
• Searching for CPT® and ICD-9-CM codes
• Screens containing information needed or
lacking
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How Do Our Patients Feel?
• Not as personable
• Computer systems is taking the attention
from the patient
• Results in poor bedside manner
• Are we talking less?
• Patients not convinced their medical
records are safe from others
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Quote by Dr. Alexander Friedman
“The traditional paper record described the
patient, what was wrong and what needed to be
done. Now the computer tells the insurance
company. The new electronic notes tell the insurer
a doctor fulfilled criteria to bill for a service.
Reimbursements are important; getting paid keeps
the doors open at hospitals and private
practices. But thorough, efficient billing doesn't
translate to better care.‖
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It‘s Not All Bad
• Not waiting for dictation
• Interface with other providers such as hospitals
to retrieve information immediately
• Legibility
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Summary
• Potential problems within your EMR
systems
• Medical Necessity
• Computer is not a Human Brain
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With automation
comes danger !!!
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Thank You
Thank You for taking time out of your busy
day to spend it with us.
