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Adding to Your

Compliance

Toolbelt: Fraud

Prevention in

Your EHR/Clinical

Documentation

April 23, 2013

Mary Pat Whaley, FACMPE, CPCManage My Practice, LLC

About Hello Health

Based in New York City80 employees27 states

Cloud-based technology coupled with a unique business model (no cost revenue-generating EHR and patient portal)

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Today’s Speaker

Mary Pat Whaley, FACMPE, CPC

• 25+ years in physician practice management

• Founder of Manage My Practice, destination website for physician practice management information and resources

• Expert in Revenue Cycle Management, Practice Management and Electronic Medical Record Management

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Overview

PROMISES PROBLEMS

• Structured Data • Structured Data

• Accessibility • Accessibility

• Meaningful Use • Meaningful Use

• Efficiency • Efficiency

• Space Saving • Space Saving

• Transcription Savings

• Lack of Transcription

• Improved Charge Capture

• Improved Charge Capture

• Alerts • Alert Fatigue

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Are You Gaming the EMR?Uproar in September

2012• The Center for Public Integrity publishes “Cracking the Codes” http://bit.ly/upcoding suggesting that costs from upcoding and other abuses likely top $11 billion between 2001 and 2010.

• Attorney general Eric H. Holder Jr., and secretary of health and human services, Kathleen Sebelius sent a letter to five hospital trade associations stating, “There are troubling indications that some providers are using this technology to game the system, possibly to obtain payments to which they are not entitled. False documentation of care is not just bad patient care; it’s illegal.”

• AHA President and CEO Rich Umbdenstock responded “more accurate documentation--a presumed result of EHR use—is not the same thing as fraud. “The AHA is still waiting on the Centers for Medicare & Medicaid Services to adopt national evaluation and management guidelines to help clarify increasingly complex payment rules.”

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Are You Gaming the EMR?Uproar in September

2012

What do you think?

Is it false documentation of care or are you simply documenting care for which you failed to collect with a paper system?

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How is EMR documentation achieved?

• Check Boxes• Check Phrases• Free Text• Dictation/Transcription• Scribes• Virtual Scribes• Voice Recognition• Handwritten

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Rule #1: The medical chart is a legal record

• Name, Patient DOB and DOS (on every page if paper)• Chief Complaint• Documentation of visit: Must demonstrate medical necessity or

evidence of a face-to-face encounter with the patient• Legible signature and date

The medical record is a legal document – would you put your name to a document that you had not reviewed?

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Rule #2: If you didn’t document it, you didn’t do it.

• Documentation isn’t done after every patient.• EMR allows billing of charges without completion of

record.• Patient never returned so no one noticed the documentation wasn’t complete.• Charging is not done through the EMR so charges got

entered before the documentation was done - no reconciliation of charges to documentation.

• Physicians leave the practice without completing the record.

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Rule #3: Every note stands on its own.

With very few exceptions, each note must be intact and include all information contributing to the level of service.

The exceptions are:• Resident Notes• Mid-level provider (MLP) notes for split/shared

visits• Addendums to the original note

EMRs handle resident and MLP notes differently – some allow notes by different providers to be part of the same note, and some do not.

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Rule #3: Every note stands on its own. (Copy and Paste, Cloning, Copying or Carrying Forward)

Definition: Copying previous documentation (same or different provider) to a note on another day, another part of the record, or even another patient’s chart.

Dangers:

Copying non-relevant data (e.g. entire problem list or even another patient’s PHI.)

Copying inaccurate or outdated information. Contradictory information.

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Rule #3: Every note stands on its own…and is expected to be unique. (Templates, Macros and Cloning)

Templates guide providers through the documentation process and prompt them to cover all standard areas of the patient visit.

Macros are blocks of text that can be “exploded” to describe standard text that applies to a service or a portion of the visit. Some macros are a standard line that is required such as “I have examined the patient and have reviewed the evaluation documented by Dan Jones, NP, and agree with his assessment and plan.” Some macros are entire paragraphs of text that allow for customization of detail.

NOTE: If an EMR converts a checklist into sentences, so that the medical records of two different patients seen for the flu are indentical, you may raise a red flag! http://bit.ly/12DgTlQ

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Rule #4: Thou Shalt Not Use Exception Documentation

Exception documentation means “all systems normal with the exception of…”

Exception documentation concerns auditors because it indicates that system are being called “normal” without actually reviewing each system.

One acceptable way to document is to click on all the individual systems examined, and to free text detail on any systems with abnormalities.

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Using Scribes

The Joint Commission defines a medical scribe as an unlicensed individual hired to enter information into the electronic health record (EHR) or chart at the direction of a physician or licensed independent practitioner. Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider.

• Scribes must login under their name/password.• Scribes may not enter orders.• Scribes may not complete/lock charts.

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Calculating the E/M Code

Some EMRs include an E/M calculator, or have you identify the levels of HPI, Exam and MDM, then suggest the level of service that corresponds.

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Split/Shared VisitsA split/shared E/M visit is an inpatient encounter where the physician and a qualified Non-Physician Provider (NPP) each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service.

Both the physician and the NPP must document the part(s) that he or she personally performed – the NPP cannot document for the physician.

There should be “bridge statement” that connects the two notes (whether on the same physical record or not), stating that the physician reviewed the documentation of the NPP (by name) and agrees with the plan and assessment, with or without changes. Typically, the physician performs the examination, even if the NPP examined the patient as well.

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Medical Students

1. Medical students services are not billable on their own.2. A medical student’s documentation for Review of Systems

(ROS) and Past, Family and Social History (PFSH) may be used to support clinical documentation and billing.

2. Attending physicians may NOT refer to a medical student’sdocumentation of history of present illness, physical

exam findings or medical decision making to support billing documentation.

3. The attending physician should review the information with the patient, reference the student’s note and document any additions/changes.

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Residents

1. Resident services are not billable on their own without any attending attestation.

2. A resident may perform the entire visit, however the attending must review his documentation.

3. The attending physician may examine the patient OR evaluate the patient, reference the resident’s note and document any additions/changes. Most healthcare organizations expect the attending physician to “lay eyes” on the patient, even if they do not examine the patient.

4. The resident’s and attending’s documentations are expected to be done on the same calendar day.

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Well and Sick Visit Same Day: One Record or Two?

CPT® says: “If an abnormality/ies is encountered or a preexisting problem is addressed in the process of performing this preventive medicine evaluation and management service and if the problem/abnormality is significant enough to require additional work to perform the key components of a problem-oriented E/M service, then the appropriate Office/Outpatient code 99201-99215 should be reported. Modifier 25 should be added to the Office/Outpatient code to indicate that a significant, separately identifiable E/M service was provided by the same physician on the same day as the preventive medicine service. The appropriate preventive medicine service is additionally reported.”

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Your EMR Compliance Toolbelt: #1 Create a Billing Compliance Policy or Update Your Current Policy

1. What is the responsibility of each person in the practice who documents in the EMR? (scribe, MA, technician, provider)

2. If the medical record and the charges are not interdependent, what is the rule for completing documentation before the charges are entered or the claim is dropped?

3. Is there a turnaround time for all provider documentation to be complete?

4. Is there a reconciliation process for making sure all documentation is complete (“locked”) and all charges are entered?

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Your EMR Compliance Toolbelt: #1 Create a Billing Compliance Policy or Update Your Current Policy

5. Are there rules for cut & paste and other methods of copying documentation from one visit to another?

6. What are guidelines for medical record addendums?

7. What is the rule about providers emptying their Inboxes before leaving for the day? How are test results handled during a provider’s absence (day off?)

8. Check with your malpractice carrier on EMR to see if using an electronic record increases or decreases risk and why.

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Your EMR Compliance Toolbelt: #2 Understand Your Electronic Medical Record

1. Is the person who set-up the EMR still employed with the practice? If not, does someone else understand the set-up?

2. Do you send someone to a user’s group meeting, or have them on a listserv, or in touch with other users?

3. Do you print out the medical record on a regular basis and see what it looks like to others – for instance, a payer or an expert witness in a trial? Can a non-physician look at the record and understand what happened at the visit?

4. Are you using the EMR’s full power?

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Your EMR Compliance Toolbelt: #2 Understand Your Electronic Medical Record

5. Do you know more now than you knew when you started with the EMR, and can you use that information to make changes? Are there tweaks you can make that would improve the medical record?

6. When was the last time someone watched the providers documenting to see what steps they take and if they are using the system as efficiently (and correctly) as possible.

7. Providers! You are legally responsible for the medical record, not the EMR vendor.

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Your EMR Compliance Toolbelt: #3 Managing Downtime

If you continue to see patients during EMR downtime (and most practices do), make sure you have a written Downtime Protocol that covers:

• Documenting a visit• Ordering tests & procedures• Making referrals• Writing prescriptions• Charging for the visit• Patient recall

Thank you & discussion

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Mary Pat Whaley, FACMPE, CPC

•www.ManageMyPractice.com

•marypat@managemypractice.com

•(919) 370-0504