Documentation and Compliance with the Electronic Health Record. The EHR and Meaningful Use

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1 Documentation and Compliance with the Where Is The Medical Necessity? Susan Roehl Health Care Consulting Manager Fargo, ND The EHR and Meaningful Use Meaningful use = incentive payments We can meet the criteria of meaningful use, but. Is the documentation meaningful? 1

2 The EHR March 20, 2012 Noridian Electronic Health Records and Future Audits (We don t like audits!!) Since EHR systems commonly autopopulate and duplicate information, providers must ensure all components of the billed E/M and other visits are medically reasonable and necessary, based on the presenting complaint and not on the type of information documented. The EHR Sources: 42CFR Parts 412,413, 422 Medicare and Medicaid Programs; Electronic Health Record Incentive Program; Medicare and Medicaid EHR Final Rule 2

3 CMS and the EHR Progress notes and templates Some templates provide limited options and/or space for the collection of information such as by using check boxes, predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical documentation to demonstrate that all coverage and coding requirements are met. (Transmittal 438, ) We will discuss this entire Transmittal later - CMS and the EHR Financial Liability The physician/lcmp should be aware that inadequate medical record documentation can lead to financial liability for the Beneficiary and/or Supplier, should the reviewer determine that a claim is not supported. 3

4 CMS and the EHR September 24, 2012 letter from USDHHS and USDOJ to AHA and other Associations: However, 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 CMS and the EHR These indications including potential cloning of medical records in order to inflate what providers get paid. There are also reports that some hospitals may be using electronic health records to facilitate upcoding of the intensity of care or severity of patients condition as a means to profit with no commensurate improvement of the quality of care. 4

5 CMS and the EHR We will not tolerate health care fraud. Does the EHR promote fraud? Without extensive free text it does not promote objective documentation and assessment. It does promote upcoding if the provider clicks all the boxes or autopopulates the fields without asking the questions or if they are not pertinent to the assessment. Autopopulation For example, the automatic generation of common negative findings within a review of systems for each body area or organ system may result in a higher level of service delivered, unless the provider documents any pertinent positive results and deletes the incorrect auto-generated entries. 5

6 As Early As 2003 NAS has noticed an increase in the use of software-generated documentation for chiropractic services. On this subject, CMS states: "Documentation should detail the specific elements of the chiropractic service for this particular patient on this day of service. It should be clear from the documentation why the service was necessary that day. Services supported by repetitive entries, lacking encounter specific information, will be denied." As Early as 2003 In general, most computerized documentation, regardless of the software used, fails to provide individualized information necessary for reimbursement. Software-generated documentation is commonly identical to the letter, comma, and space for different patients, with only minor word changes; therefore, it does not reflect medical necessity. Services supported by repetitive entries lacking encounter specific information will be denied. 6

7 As Early as 2003 Daily notes need to be encounter specific for each date of service and contain both qualitative and quantitative elements evident for the subjective and objective portions of the documentation. Without this information, it is difficult for a reviewer to assess the true clinical picture of the patient, in regard to the severity of his/her condition. What may be appropriate for one patient, may not be enough or required on another patient or visit.. As Early as 2003 Factors that must be taken into consideration when treating and documenting: Age Severity of condition Past response to treatment Frequency of treatment Complicating factors Software-generated documentation often repeats the same phrases and sentences by simply rearranging the words to make it appear as if new information is being disseminated, but when compared to prior days notes, reflects the same or similar concepts. Reposted by Noridian 10/13/2010 7

8 Do you see what I see? Daily progress notes that are a clone of the previous day s documentation = red flag Resolved issues documented as if they were still current Templates that indicate all negative or no Why is the patient here? Where is the medical necessity? Do you see what I see? Patient treated in ER for a small finger laceration Every Body System in the Review of Systems is addressed A head to toe Physical Examination is documented REALLY?? Non-medically necessary system reviews and examinations should not be included in the Evaluation and Management level assignment Do your Providers know the E/M guidelines? Do your coders know the E/M guidelines? 8

9 Do you see what I see? Previous eye enucleation Review of Systems Eyes Normal checked Physical Examination Pupils react to light and accommodation checked. No significant findings checked. Really? Do you see what I see? Patient with a previous above knee amputation right leg Review of Systems Musculoskeletal No reported symptoms Physical Examination Extremities Good muscle tone and strength bilateral. Gait normal. Really? 9

10 The Dangers of Copy and Paste Cut and paste, copy and paste, cloning, carry forward whatever you call it may misrepresent the patient s current condition Contradictions are seen throughout the record when copy and paste is utilized When a provider brings forward other clinicians and nursing documentation, he is taking responsibility that it is correct The Dangers of Copy and Paste An entire progress note that is copied and pasted or brought forward does not signify any involvement of this provider in the patient s assessment and care for that date (other than they have acquired some technology skills ) There is no reportable service for the provider for that date 10

11 The Dangers of Copy and Paste Documentation is critical To support an admission from Observation to Inpatient status To support a one or two day Inpatient stay To support the medical necessity of a surgical procedure To support Lab and X-ray procedures Integrity of Clinical Documentation Medical necessity concerns are not new with the EHR They are compounded by a record in which templates and check boxes are the only documentation present on the record Physician documentation that was substandard in the paper record is not improved in the EHR 11

12 Integrity of Clinical Documentation Data quality and information integrity must be prioritized. If clinical documentation was inaccurate when used for billing or legal purposes, it was wrong when it was used by another clinician, another provider at transition, a researcher, the public health authority, or quality reporting agency. AHIMA In testimony before the Office of the National Coordinator HIT Policy Committee, made its case that suboptimal clinical documentation in the EHR is a problem that needs addressing. February 2013 Integrity of Clinical Documentation A study reported in the July-August 2004 issue of the Journal of the American Medical Informatics Association measured the impact of computerized physician documentation at a teaching hospital. The authors, who interviewed resident physicians and faculty, identified the following three problem areas: Redundancy: The same information and misinformation was repeated. It was also difficult to identify where the misinformation began. 12

13 Integrity of Clinical Documentation Formatting: Staff had trouble segregating useful information stuff you care about from meaningless data in the endless notes. Decreased confidence in the material: One person interviewed said the progress notes made it appear that the same physical exam was performed by an intern, a resident, an attending physician, and a subspecialist. Cluttered Paper notes were 90% clutter free People didn t put gibberish in hand written notes. EHR s on the other hand, have 60% clutter in them. Clutter is stuff on the page with no value added to it. Brian Jacobs, MD, Executive Director Children s National Medical Center CIO and CMIO Washington, D.C. 13

14 The Problem Problem List The Problem List - a requirement of meaningful use But, does it have any meaning? The EHR does not prompt the provider to add (or chose not to add) diagnoses to the Problem List, at least in the hospital setting This can become automated in some systems. It should always be a provider decision The Problem Problem List The problem list is for nontransitive illnesses. This is the official definition used in the Federal Meaningful Use program. Most providers ignore the Problem List because: It is not current or valid It is not consistent It is not maintained Whose responsibility is it? Nurses add to it Coders add to it Do NOT code from the Problem List 14

15 EHR Shortcomings Physician documentation in the EHR has been designed for reimbursement purposes, as opposed to documentation of specificity, complications, and comorbidities Meaningful use requirements have been built in Nursing and ancillary documentation in the EHR has been designed to check all the boxes for State and JCAHO requirements, as opposed to reporting a clear picture of the patient's condition Legal Aspects Potential for bringing forth billable procedures that were not performed at this visit Copy and paste in the record decreases the credibility of the record from an auditing and medico-legal aspect Lack of editing, auditing, and review creates chaos in the record What would a lawyer do with this record? Rip it apart! 15

16 Once an error, always an error Information that is incorrect, and then is autopopulated, brought forward, or copied and pasted takes on a life of it s own Drop down boxes are great assistants, but a wrong click is there to stay An incorrect drug allergy is now populated throughout an entire medical record Payers are taking note Noridian Palmetto First Coast Service Options Aetna Indian Health Services National Government Services All have published statements or policies regarding cloned documentation. 16

17 OIG "As systems transition toward quality- and outcomes-based payment systems, law enforcement will be presented with new challenges. Investigators will need the skills to determine the reliability of data used for measuring quality and performance because false data could skew payments." Daniel R. Levinson Inspector General In the Justification of Estimates for the Appropriations Committee ICD-10 and the EHR The EHR should assist providers with the detailed specificity required with ICD-10 However, the systems were designed without end user input, especially from the coding community Verify with your vendor the EHR will be updated to accept ICD-10 codes and documentation 17

18 ICD-10 and the EHR Custom templates and drop down boxes SHOULD include the details required (i.e.) Initial or Subsequent visit, or Sequela Right or Left side Specificity per fracture site which finger (1-4 or thumb), which part of the finger (distal, shaft, proximal) Detailed documentation = detailed severity of illness documentation! Worse Case Scenario While Patient A was a patient at Medical Center A, a number of medical tests and diagnostic evaluations were performed in an outpatient clinic over a two-week period. Concern arose about the health plan claim, so Patient A requested a copy of his medical record along with the bill for services. The statement included Evaluation and Management codes consistently reported at the highest level of service (level 5). 18

19 Worse Case Scenario Because Patient A is a retired auditor for health plans, he examined the documentation and discovered that the medical history was pulled through within departments, between departments, and in subsequent visits with the same provider using the Electronic Health Record (EHR) system, even when the visits did not include the clinician taking a history. The health plan was billed for a high level of service (of history) for each hospital outpatient clinic visit. Worse Case Scenario Patient A is concerned that the EHR does not have the functionality (or it is not used) to show that the history (or any documentation component) obtained during a previous encounter was copied and reused as documentation for subsequent visits to support physician intensity of service. After many attempts to have services billed at the correct level (what Patient A insists is really a level 2 or 3 Evaluation and Management when the pulled through data are not considered for service intensity), he contacts the fraud division of the health plan about his concerns. "Integrity of the Healthcare Record: Best Practices for EHR Documentation." Journal of AHIMA 84, no.8 (August 2013): 19

20 Bad Example The EKG order is in the electronic order format only, and it does appear to be signed by the physician. The indication for the EKG on the telephone order is chest pain. This is the only documentation on the record of chest pain that we could locate. There is no nursing documentation that corresponds with the time of order, and the pain assessment two hours prior was N in the archived Discharge Summary nursing documentation portion of the electronic record, which is over 40 pages. Bad Example There are additional archived notes two pages of nursing notes with free text that includes one note which states the patient has chest pain. This is not included in the 40+ pages as noted previously?? Chest pain is not included in any physician documentation, including the progress note for that date. We do not recommend reporting chest pain (786.50) which is only documented in a telephone order. 20

21 Bad Example IV Levaquin was started at 1402, but there is no documentation when it was discontinued (patient suffered an adverse reaction) on the Medication Discharge Summary. In the Archived Notes document timed 1419, nursing states IV Levaquin was discontinued; however, we cannot determine if this is the time of the note or the time the Levaquin was discontinued. Report IV push, initial, due to the lack of accurate documentation. Policy and Procedure Needs Abbreviations ICBG -? Iliac crest bone graft. Documented by a hospitalist on 5 fusion records, however, none had this procedure ED physician - Patient being treated with Augmentin for PNA. PNA is not a standard abbreviation - does it indicate pulmonary nodular amyloidosis, or pneumonia, or one of the other several potential translations of PNA? Typos - Do you have editing policies? 21

22 Policy and Procedure Needs Voice recognition software Training of software required Approval per individual employee (following documentation review) recommended Subjective patient states that she fell on naproxen marcated injured left shoulder His blood pressure a first person labile that after has not been intubated and sedate it has normalized. Policy Statement Example Electronically signing documentation containing nonsensical or grammatical errors. Do not sign clinical documentation that contains grammatical errors, nonsensical statements, or incomplete information. Your electronic signature is a confirmation that the medical record note is accurate, complete, and free of omissions. Noridian encourages providers to proofread all documentation prior to signing the note to avoid potential payment denials. 22

23 Policy and Procedure Needs Copy and Paste Limited use recommended Carry Forward Last visit note is brought forward for editing also very high risk for inaccurate information and upcoding Copy and Paste and Carry Forward only allowed for the SAME provider or staff member Cannot copy or carry forward another provider or staff member s documentation as if it were your own If Lab or X-ray findings are copied and pasted, they must be addressed specifically to the patient s condition and treatment Policy and Procedure Needs Auto-Population If the provider clicks a box, automatic detailed examination or history is documented (do NOT recommend) very high risk Our highest level of discrepancy during documentation and coding reviews when compared to other documentation in the record Twenty physician records reviewed Every visit note contained identical Review of Systems and Exam 23

24 Audits of the EHR Since EHR systems commonly auto-populate and duplicate information, providers must ensure all components of the billed E&M and other visits are medically reasonable and necessary - based on the presenting complaint and not on the type of information documented. Noridian Medicare Part A Electronic Health Records and Future Audits 3/20/12 Policy Statement Example Do not use generalized or auto-populated statements within Evaluation and Management documentation if it does not support the individual patient s clinical management. Documentation that contains cloned, identical statements from patient to patient with no evidence of clinical relevance can be perceived as fraudulent when reviewed by a third party. Such documentation does not demonstrate quality patient care and may result in payment denial. 24

25 Copy/Paste/Carry Forward All Copy and Paste and Carry Forward notes require a notation and date i.e., Family History is commonly carried forward, as it rarely changes. Notation Reviewed and unchanged Past History notation reviewed Updated to note an episode of acute cholecystitis on from which the patient recovered without surgical intervention. Policy and Procedure Needs Data Gathering: All data carried forward or cut and pasted must identify the source document and date Documentation of review of the imported data and it s impact on the decision making and treatment of the patient 25

26 Policy and Procedures Needs Coding Guidelines in relationship to the review of previously documented data Where may information be obtained to assign codes for an episode of care? Only documentation present and addressed during the current episode should be utilized for code assignment Policy and Procedure Needs Consistent documentation Every staff member documents the same item in the same place Medications Start and Stop time of infusions and injections Admission note and time Discharge note and time Response to medication and treatment 26

27 The Use of Templates CMS does not prohibit the use of templates to facilitate record-keeping. CMS also does not endorse or approve any particular templates. A physician/lcmp may choose any template to assist in documenting medical information. The Use of Templates, continued Some templates provide limited options and/or space for the collection of information such as by using check boxes, predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. 27

28 The Use of Templates, continued Physician/LCMPs should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met. This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met. The Use of Templates, continued If a physician/lcmp chooses to use a template during the patient visit, CMS encourages them to select one that allows for a full and complete collection of information to demonstrate that the applicable coverage and coding criteria are met. Centers for Medicare & Medicaid Services (CMS) Transmittal 438 Date: November 9,

29 Policy and Procedure Needs We highly recommend pertinent free text requirements of both physician/midlevel providers and nursing/clinical staff at least once per day or shift. We highly recommend dictated History and Physicals and Discharge Summaries, rather than templated documents. If a template is adopted, free text in all sections should be required. Policy and Procedure Needs Observation Services This is an hourly charge, so documentation must support the continued medical necessity of this service Provider documentation must support the medical necessity of the need for Observation AND the indications for a transfer to Inpatient status 29

30 Policy and Procedure Needs Observation, continued Clear documentation of when the patient is away from the nursing floor receiving other services (i.e., Radiology, Physical Therapy, surgical procedures). These times should be subtracted from the Observation hours. Clear documentation of start and stop times of transfusions, chemotherapy, or closely monitored infusions. These times should be subtracted from the Observation hours. Policy and Procedure Needs Policy for copying of medical records requested by payers and auditors Be cognizant of the reason for the request Do NOT copy all of the electronic record unless mandated by release of information requirements. One record may fill the back end of a pick up If diagnoses codes have been assigned from previous episodes, herein lies the problem 30

31 Policy and Procedure Needs Release of Information RAC, CERT, ZPIC, and other payer audit requests should be reviewed by UR, Quality Management, or another employee who can highlight, tab, or indicate in some method where to find pertinent information Reviewers will not spend hours looking for the information they require Conclusion The EHR is a useful tool in health care documentation, but carries a high risk in upcoding and fraud. The medical record has always, and will continue to be, a medical-legal document. The provider and staff member signatures indicate they are attesting all information is accurate and reflects the care THEY gave. 31

32 Conclusion Provider documentation does not need to be lengthy and cumbersome it needs to address the condition of the patient and the provider s assessment, rationale for treatment, medical necessity AND review of the tests ordered and how they will used in the treatment of the patient. Policies and procedures, review of documentation, and enforcement of policies is required for a compliant EHR. Questions? Sue Roehl, RHIT, CCS [email protected] This presentation is presented with the understanding that the information contained does not constitute legal, accounting or other professional advice. It is not intended to be responsive to any individual situation or concerns, as the contents of this presentation are intended for general informational purposes only. Viewers are urged not to act upon the information contained in this presentation without first consulting competent legal, accounting or other professional advice regarding implications of a particular factual situation. Questions and additional information can be submitted to your Eide Bailly representative, or to the presenter of this session. 32