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Leveraging Your EHR for Compliance


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Recent changes to the Health Information Portability and Accountability Act (HIPAA) have brought stiffer penalties for fraud prevention, with new levels of enforcement among smaller and independent medical practices. Electronic medical record users should be aware of issues that pertain to electronic documentation compliance, including patient identification and demographic accuracy; and documentation, auditing and authorship integrity. This webinar reviews these and other concepts, including:

Are you “gaming” the EMR?
Locking the record before billing
Cut and paste rules
Macro/template rules
Using a scribe
Choosing the E/M Code
Closing the order to bill
Rules for split/shared visits
Rules for documentation by medical students and residents
Providing a well visit and a sick visit at the same time

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Leveraging Your EHR for Compliance

  1. 1. Sponsored by:Adding to YourComplianceToolbelt: FraudPrevention in YourEHR/ClinicalDocumentationApril 23, 2013Mary Pat Whaley, FACMPE, CPCManage My Practice, LLC
  2. 2. About Hello HealthBased in New York City80 employees27 statesCloud-based technology coupledwith a unique business model (nocost revenue-generating EHR andpatient portal)
  3. 3. Today’s Speaker3Mary Pat Whaley, FACMPE, CPC• 25+ years in physician practicemanagement• Founder of Manage My Practice,destination website for physicianpractice management informationand resources• Expert in Revenue CycleManagement, Practice Managementand Electronic Medical RecordManagement
  4. 4. Overview4PROMISES PROBLEMS• Structured Data • Structured Data• Accessibility • Accessibility• Meaningful Use • Meaningful Use• Efficiency • Efficiency• Space Saving • Space Saving• TranscriptionSavings• Lack ofTranscription• Improved ChargeCapture• Improved ChargeCapture• Alerts • Alert Fatigue
  5. 5. Are You Gaming the EMR?Uproar in September 20125• The Center for Public Integrity publishes “Cracking the Codes” suggesting that costs from upcoding and other abuseslikely top $11 billion between 2001 and 2010.• Attorney general Eric H. Holder Jr., and secretary of health and humanservices, Kathleen Sebelius sent a letter to five hospital trade associationsstating, “There are troubling indications that some providers are using thistechnology to game the system, possibly to obtain payments to which theyare not entitled. False documentation of care is not just bad patient care; it’sillegal.”• AHA President and CEO Rich Umbdenstock responded “more accuratedocumentation--a presumed result of EHR use—is not the same thing asfraud. “The AHA is still waiting on the Centers for Medicare & MedicaidServices to adopt national evaluation and management guidelines to helpclarify increasingly complex payment rules.”
  6. 6. Are You Gaming the EMR?Uproar in September 20126What do you think?Is it false documentation of care or are yousimply documenting care for which you failed tocollect with a paper system?
  7. 7. How is EMR documentation achieved?7• Check Boxes• Check Phrases• Free Text• Dictation/Transcription• Scribes• Virtual Scribes• Voice Recognition• Handwritten
  8. 8. Rule #1: The medical chart is a legal record8• Name, Patient DOB and DOS (on every page if paper)• Chief Complaint• Documentation of visit: Must demonstrate medical necessity orevidence of a face-to-face encounter with the patient• Legible signature and dateThe medical record is a legal document – would youput your name to a document that you had notreviewed?
  9. 9. Rule #2: If you didn’t document it, you didn’t do it.9• Documentation isn’t done after every patient.• EMR allows billing of charges without completion ofrecord.• Patient never returned so no one noticed thedocumentation wasn’t complete.• Charging is not done through the EMR so charges gotentered before the documentation was done - noreconciliation of charges to documentation.• Physicians leave the practice without completing therecord.
  10. 10. Rule #3: Every note stands on its own.10With very few exceptions, each note must be intact andinclude all information contributing to the level ofservice.The exceptions are:• Resident Notes• Mid-level provider (MLP) notes for split/sharedvisits• Addendums to the original noteEMRs handle resident and MLP notes differently – someallow notes by different providers to be part of the samenote, and some do not.
  11. 11. Rule #3: Every note stands on its own. (Copy andPaste, Cloning, Copying or Carrying Forward)11Definition: Copying previous documentation (same ordifferent provider) to a note on another day, another partof the record, or even another patient’s chart.Dangers: Copying non-relevant data (e.g. entire problem list oreven another patient’s PHI.) Copying inaccurate or outdated information. Contradictory information.
  12. 12. Rule #3: Every note stands on its own…and isexpected to be unique. (Templates, Macros andCloning)12Templates guide providers through the documentation processand prompt them to cover all standard areas of the patient visit.Macros are blocks of text that can be “exploded” to describestandard text that applies to a service or a portion of the visit.Some macros are a standard line that is required such as “I haveexamined the patient and have reviewed the evaluationdocumented by Dan Jones, NP, and agree with his assessmentand plan.”Some macros are entire paragraphs of text that allow forcustomization of detail.NOTE: If an EMR converts a checklist into sentences, so that themedical records of two different patients seen for the flu areindentical, you may raise a red flag!
  13. 13. Rule #4: Thou Shalt Not Use ExceptionDocumentation13Exception documentation means “all systems normal withthe exception of…”Exception documentation concerns auditors because itindicates that system are being called “normal” withoutactually reviewing each system.One acceptable way to document is to click on all theindividual systems examined, and to free text detail on anysystems with abnormalities.
  14. 14. Using Scribes14The Joint Commission defines a medical scribe as anunlicensed individual hired to enter information into theelectronic health record (EHR) or chart at the direction of aphysician or licensed independent practitioner. Scribes arenot permitted to make independent decisions ortranslations while capturing or entering information intothe health record or EHR beyond what is directed by theprovider.• Scribes must login under their name/password.• Scribes may not enter orders.• Scribes may not complete/lock charts.
  15. 15. Calculating the E/M Code15Some EMRs include an E/M calculator, or have you identifythe levels of HPI, Exam and MDM, then suggest the levelof service that corresponds.
  16. 16. Split/Shared Visits16A split/shared E/M visit is an inpatient encounter where the physicianand a qualified Non-Physician Provider (NPP) each personally performa substantive portion of an E/M visit face-to-face with the samepatient on the same date of service. A substantive portion of an E/Mvisit involves all or some portion of the history, exam or medicaldecision making key components of an E/M service.Both the physician and the NPP must document the part(s) that he orshe personally performed – the NPP cannot document for thephysician.There should be “bridge statement” that connects the two notes(whether on the same physical record or not), stating that thephysician reviewed the documentation of the NPP (by name) andagrees with the plan and assessment, with or without changes.Typically, the physician performs the examination, even if the NPPexamined the patient as well.
  17. 17. Medical Students171. 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 beused to support clinical documentation and billing.2. Attending physicians may NOT refer to a medical student’sdocumentation of history of present illness, physical examfindings or medical decision making to support billingdocumentation.3. The attending physician should review the informationwith the patient, reference the student’s note anddocument any additions/changes.
  18. 18. Residents181. Resident services are not billable on their own withoutany attending attestation.2. A resident may perform the entire visit, however theattending must review his documentation.3. The attending physician may examine the patient ORevaluate the patient, reference the resident’s note anddocument any additions/changes. Most healthcareorganizations 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 areexpected to be done on the same calendar day.
  19. 19. Well and Sick Visit Same Day: One Record or Two?19CPT® says: “If an abnormality/ies is encountered or apreexisting problem is addressed in the process ofperforming this preventive medicine evaluation andmanagement service and if the problem/abnormality issignificant enough to require additional work to performthe key components of a problem-oriented E/M service,then the appropriate Office/Outpatient code 99201-99215should be reported. Modifier 25 should be added to theOffice/Outpatient code to indicate that a significant,separately identifiable E/M service was provided by thesame physician on the same day as the preventivemedicine service. The appropriate preventive medicineservice is additionally reported.”
  20. 20. Your EMR Compliance Toolbelt: #1 Create a BillingCompliance Policy or Update Your Current Policy201. What is the responsibility of each person in thepractice who documents in the EMR? (scribe, MA,technician, provider)2. If the medical record and the charges are notinterdependent, what is the rule for completingdocumentation before the charges are entered orthe claim is dropped?3. Is there a turnaround time for all providerdocumentation to be complete?4. Is there a reconciliation process for making sure alldocumentation is complete (“locked”) and allcharges are entered?
  21. 21. Your EMR Compliance Toolbelt: #1 Create a BillingCompliance Policy or Update Your Current Policy215. Are there rules for cut & paste and other methodsof copying documentation from one visit toanother?6. What are guidelines for medical recordaddendums?7. What is the rule about providers emptying theirInboxes before leaving for the day? How are testresults handled during a provider’s absence (dayoff?)8. Check with your malpractice carrier on EMR to seeif using an electronic record increases or decreasesrisk and why.
  22. 22. Your EMR Compliance Toolbelt: #2 Understand YourElectronic Medical Record221. Is the person who set-up the EMR still employedwith the practice? If not, does someone elseunderstand the set-up?2. Do you send someone to a user’s group meeting, orhave them on a listserv, or in touch with otherusers?3. Do you print out the medical record on a regularbasis and see what it looks like to others – forinstance, a payer or an expert witness in a trial? Cana non-physician look at the record and understandwhat happened at the visit?4. Are you using the EMR’s full power?
  23. 23. Your EMR Compliance Toolbelt: #2 Understand YourElectronic Medical Record235. Do you know more now than you knew when youstarted with the EMR, and can you use thatinformation to make changes? Are there tweaksyou can make that would improve the medicalrecord?6. When was the last time someone watched theproviders documenting to see what steps they takeand if they are using the system as efficiently (andcorrectly) as possible.7. Providers! You are legally responsible for themedical record, not the EMR vendor.
  24. 24. Your EMR Compliance Toolbelt: #3 ManagingDowntime24If you continue to see patients during EMR downtime(and most practices do), make sure you have a writtenDowntime Protocol that covers:• Documenting a visit• Ordering tests & procedures• Making referrals• Writing prescriptions• Charging for the visit• Patient recall
  25. 25. Thank you &discussion
  26. 26. 26Mary Pat Whaley, FACMPE, CPC•••(919) 370-0504