IMPLEMENTING AND MAINTAINING ELECTRONIC MEDICAL RECORDS

Transcription

1 IMPLEMENTING AND MAINTAINING ELECTRONIC MEDICAL RECORDS A Guide to EMR Utilization and Compliance Risks for s, IT Professionals, and Administrators

2 Prepared by: Dawnese Kindelt, CPC, CHC - System Compliance Director Clinics/ Services John Wright, CPC, CPMA System Coding Compliance Manager - Clinics Deborah Barnes, CMA, CPC, CPMA System Coding Compliance and Reimbursement Specialist Draft date: May 9, 2012 Last Updated: May 15, 2012 Copyright 2012 Dignity Health. For internal Use only. Copyright Note: This document was created exclusively for Dignity Health. Much of the content and formatting is based on ELECTRONIC MEDICAL RECORD PLAYBOOK 2010 Texas Tech University Health Sciences Center, pursuant to permission from Texas Tech University Health Sciences Center, March 10, 2011.

3 TABLE OF CONTENTS I. EVALUATION AND MANAGEMENT (E/M) CODE SELECTION & PROMPTS... 1 A VS DOCUMENTATION GUIDELINES -WHICH WILL BE USED TO CALCULATE LEVEL OF SERVICE?... 1 B. E/M TEMPLATES Exploding/Pre-populated Elements Cloned/Copy and Paste Function...3 C. AUTOMATED EVALUATION AND MANAGEMENT CODE ASSIGNMENT... 4 D. VOICE RECOGNITION SOFTWARE... 4 II. TEACHING PHYSICIAN DOCUMENTATION... 5 A. EMR TEACHING PHYSICIAN MACROS... 5 B. MEDICAL STUDENT DOCUMENTATION... 5 III. DOCUMENTATION BY SCRIBES... 6 IV. OTHER DOCUMENTATION REQUIREMENTS... 7 A. TIME-BASED CODES... 7 B. AUTHORSHIP... 7 C. CORRECTIONS/AMENDMENTS AND AUDIT TRAILS... 8 V. ADDITIONAL RESOURCES... 9 APPENDIX A - TEACHING PHYSICIANS ELECTRONIC MEDICAL RECORD MACROS ONLY... 10

4 The primary purpose of this document is to educate providers and their staff, IT professionals, and facility management on potential risks that may arise when implementing an EMR, and to provide some initial recommendations. The information contained in this document is a resource for Dignity Health to utilize during the on-going implementation and on-going use of electronic medical record (EMR) systems at Dignity Health. With this knowledge base, leaders, providers, and their staff can seek further guidance from their Facility Compliance Liaison (FCL) or Corporate Compliance staff to minimize the risk of improper documentation that could result in fraud/abuse liability. This document includes best practices as outlined by professional associations, the Center for Medicare and Medicaid Services (CMS) as well as lessons learned from other healthcare institutions that have EMR systems in place, as well as our own experiences. Some of the recommendations stated in this document will be the basis of future Compliance policies and procedures at which time this guidebook will be updated to reference those policies. I. EVALUATION AND MANAGEMENT (E/M) CODE SELECTION & PROMPTS The Center for Medicare and Medicaid Services (CMS) has published two sets of documentation guidelines for leveling of Evaluation and Management (E/M) Services. Providers are able to utilize either set of guidelines, and CMS has indicated they will audit to whichever set is more advantageous to the provider. Dignity Health applies this same logic, and does not require any entity to choose one set over the other. This is an important issue if the clinic decides to use tools within the EMR system to identify the level of E/M code based on the provider s documentation in the EMR. Exclusive use of the 1995 or 1997 Documentation Guidelines (DG) for E/M services may not accurately reflect the true level of service provided. For example, our experience indicates the 1995 guidelines allow more flexibility for a primary care provider, but the 1997 single system criteria is more appropriate for specialists such as orthopedics or cardiology. This is discussed in more detail below. Dignity Health policy outlines medical necessity as it applies to E/M services. Specifically, medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level is warranted for the presenting illness. The volume of documentation should not be the primary influence upon which a specific level of service is billed. A vs Documentation Guidelines - Which will be used to Calculate Level of Service? The 1995 Documentation guidelines (DG) are designed for use when a general multisystem encounter/exam is performed. The 1997 Documentation Guidelines (DG) contain single organ system exams which are specialty specific and may be better suited to the practice of a specialty provider. Page 1

5 Again, creating templates with only 1995 guidelines may result in lower levels of service for specialist, such as Orthopedics, Ophthalmology, or Cardiology DG may not be advantageous to general practitioners and general internal medicine providers because the criteria for reaching a general multi-system exam are more stringent than the Documentation Guidelines - Recommendation of System Compliance Office At this time, the System Compliance Office follows CMS standards, which indicate that either the 1995 or 1997 DG may be used to code and/or audit E/M services, whichever is most advantageous to the provider. It is recommended that both the 1995 and 1997 DG be made available within the EMR applications so that the provider and/or coder determine which set allows for complete clinical documentation and supports the level of service provided to the patient. B. E/M Templates A Template in an EMR is a tool for organizing, presenting and capturing clinical data within the system. 1 EMR templates can make documentation faster and easier and allow for reporting of quality measures. Some EMR products include template features, such as exploding notes, auto-population, pre-population, default documentation, cut and paste, copy forward and macro 2 features that can result in too much information being replicated from one encounter to the next, or from one patient to the next. This results in little to distinguish the unique nature of each patient encounter, thus failing to support medical necessity, according to Medicare Carriers and the Office of the Inspector General (OIG). Documentation automatically entered, by way of EMR functions, that is not relevant to what was performed or what was medically necessary for the current encounter should not be counted for billing purposes. Template features should be utilized by the provider to prompt documentation of medically necessary information, not to do the lion s share of the documentation. The recommendation of the System Compliance Office is to encourage providers to use the information available through the EMR to customize the patient s medical record so that the integrity and accuracy of the information cannot be put into question, whether it is for billing purposes or patient care. 1. Exploding/Pre-populated Elements Exploding notes and exploding macros refer to functionality that allows a provider to document several elements of history or exam with a single click. By clicking or checking normal or negative the EMR then populates documentation of a complete element, even though all elements may not have been performed during In this context a macro is a series of commands grouped together as a single command that are recorded and saved under a short key code or macro name. A macro can be used to add blocks of text that is used over and over again. Page 2

6 the encounter. This function, if not properly utilized by the provider, can take over the documentation and result in erroneous information in the final record. EXAMPLE: The provider selects Normal GI exam and the EMR automatically populates the medical record with all GI descriptions, such as abdomen soft and nontender, normal bowel sounds, not distended, no organomegaly even though the provider may not have examined all of those GI areas. Pre-populated functionality automatically creates documentation of a complete exam with the expectation the provider will edit the template to indicate abnormal findings and note items not examined during the encounter. If the provider does not perform an edit of each entry to reflect the actual encounter, the record may contain inconsistent statements, or result in a higher level of E/M service than medically necessary. Exploding Elements Recommendation of System Compliance Office i. If pre-population functionality is utilized, the default should be to not examined, allowing the provider to identify each abnormality. It is acceptable to utilize a one click functionality that indicates all other systems reviewed and found to be normal, which would then complete the documentation of the encounter. ii. Ideally, each campus should consider establishing a multi-disciplinary committee, including coding or compliance staff, to review and approve EMR templates to ensure that they result in accurate, unique encounter documentation. 2. Cloned/Copy and Paste Function Documentation created by this method must be accurate and complete. It must reflect the services provided to the patient on the day and time of the specific encounter A feature of most EMR systems is the ability to copy and paste (i.e., clone) documentation from a previous patient encounter or from another patient s medical record. Cloned documentation refers to medical record documentation that is identical regardless of the patient involved; or in the case of the same patient, regardless of the date of service. EMR system features that may exist include, among others: (a) copy and paste functions; (b) copy note forward; (c) save note as template; and/or (d) make me the author. As outlined above, this may result in documentation that does not reflect the unique nature of the encounter leading to questions of the medical necessity of visits. The Office of Inspector General (OIG) has included EMR use, including cloning, in its Fiscal Year 2011 and 2012 Work Plans 3, indicating they will conduct audits of 3 OIG Work Plan, Fiscal Year 2011 at: Page 3

7 electronic medical records to determine if there is inappropriate use of cloning/copy & paste/carry forward functions that result in improper claims and payments. This risk area will also be included in the scope of the routine audits conducted by the Corporate Compliance team beginning FY13. Recommendations of System Compliance Office The System Compliance Office recognizes the value of allowing these tools to ease documentation burdens for the provider. However, each facility should have a monitoring process in place to ensure risks are identified and mitigated. This risk area will also be included in the scope of the routine audits conducted by the Corporate Compliance team beginning FY13. C. Automated Evaluation and Management Code Assignment Many vendors promote the EMR functionality to automatically calculate the E/M CPT code based on the number of boxes completed during the encounter. Unfortunately, the computer has no built-in logic to determine which elements are medically necessary for the treatment of the presenting problem, which were auto-populated but not necessary for the encounter, such as past, family or social history, and which were screening in nature. The physician, who is contracted with the payers, including Medicare, is ultimately responsible for the accuracy of the claims submitted on his/her behalf. This functionality should be used with extreme caution. Recommendations of System Compliance Office Providers should not depend on the accuracy of codes assigned by the system. They should verify the level of service is medically necessary prior to submitting codes for billing. The clinical examples list in Appendix C of the AMA CPT code book is an excellent reference of E/M levels. Additionally, some systems allow a facility to ensure the level of Medical Decision Making (MDM) meets or exceeds the level of service coded. Please contact the System Compliance Office if you have additional questions, or intend to activate the E/M leveler in your EMR. D. Voice Recognition Software Voice/speech recognition software, such as Dragon, can assist in leveraging the physician time during documentation, by automatically transcribing dictation. American Health Information Management Association (AHIMA) has published guidance related to this tool, indicating [speech recognition] is not, in and of itself, the final solution in clinical documentation. Speech recognition used directly by the physician/provider, in conjunction with an EMR becomes a viable option for more complete documentation Page 4

8 This emerging technology requires all documentation to be proof read for misunderstood terms and concepts. The provider must edit and populate missed fields prior to finalizing the record and submitting codes for claims processing. Voice Recognition Software Recommendations of the System Compliance Office The System Compliance Office recognizes the value of allowing these tools to ease documentation burdens for the provider. However, each facility should have a monitoring process in place to ensure risks are identified and mitigated. II. TEACHING PHYSICIAN DOCUMENTATION A. EMR Macros In the content of an EMR, the term macro means a command in a computer or dictation application that automatically generates predetermined text that is not edited by the user. When using an EMR, it is acceptable for the teaching physician to use a macro as the required personal documentation if the (TP) adds it personally in a secured (password protected) system. In addition to the teaching physician s macro, either the resident or the TP must provide customized information that is sufficient to support a medical necessity determination. The note in the EMR must sufficiently describe the specific services furnished to the specific patient on the specific date. It is insufficient documentation if both the resident and TP use macros only. This information is detailed in Dignity Health policy Macros Recommendation of System Compliance Office i. Approved Macros: The System Compliance Office provides suggested teaching physician macros for Dignity Health EMR systems, based on CMS direction, which are attached as Appendix A. Please contact the System Compliance office before using a macro significantly different than what is provided herein. ii. Macros Safeguards: The EMR must allow only the teaching physician to add the teaching physician macro for those services that must be personally documented by the teaching physician. This includes E/M services, time-based services, and psychotherapy services (along with any additional documentation required) via a secured password. In the hospital setting, it would also include anesthesia services and overlapping surgeries. These macros or supporting documentation cannot be added by residents or other staff members. This will require role-based access to various areas within the EMR. B. MEDICAL STUDENT DOCUMENTATION While the medical student s documentation of clinical care is an important educational tool, the use of the medical student s documentation to support a billable service is very limited. The medical student s documentation of History, Exam or Medical Decision Making cannot be used to support an E/M service, nor can cut/paste or make me the author functionality be used for purposes of the teaching physicians records. Page 5

9 III. DOCUMENTATION BY SCRIBES Dignity Health policy titled Scribe Services, indicates physicians, and nonphysician practitioners may be permitted to utilize the services of qualified, trained, and competent clerical staff referred to as scribes ( Scribes ) to improve medical record documentation speed and accuracy. The provider is ultimately responsible for all documentation in the medical record, including the entries made by the Scribes. The provider must ensure that all documentation in the medical record conforms with facility policy, the requirements of Joint Commission, if applicable, and other applicable legal requirements. CMS supports this policy indicating clerical staff may act as a scribe by documenting the physicians words and activities during the encounter. All E/M guidelines for place of service, documentation of medical necessity and key components remain the same. The direction goes on to indicate documentation must include the name of the person acting as a scribe, and the physician must then sign the note indicating it is an accurate record of his/her words and actions during that visit. 5 Use of Scribe Recommendations of the System Compliance Office Similar to the Macros outlined above, a macro can be created to reflect the identity of the scribe, and be co-signed by the treating physician. Example: Entry written by [insert name], acting as a scribe for Dr. [insert name]. The treating provider would then indicate, This note accurately reflects the work and decisions made by me, during the encounter. The treating provider is ultimately responsible for the accuracy of the documentation. The same role based safeguards as described in Macro section, must be employed for scribe macros. 5 CMS IOM, Publication , Chapter 12, Section Page 6

10 IV. OTHER DOCUMENTATION REQUIREMENTS A. Time-Based Codes Medicare has specific documentation requirements for time-based codes. In particular, the EMR should allow appropriate documentation of face-to-face time spent in psychotherapy, prolonged service, critical care, tobacco cessation counseling, and counseling/coordination of care when it constitutes more than 50% of the E/M service. 1. Psychotherapy Services, critical care, tobacco cessation and prolonged services: These services are billed based on total face-to-face time spent with the patient; therefore the medical record must reflect the time spent either as total time or as time in and time out. 2. Counseling/Coordination of Care: When counseling and/or coordination of care dominates more than 50% of the total face-to-face time with the patient and/or family in an encounter, then the E/M level may be selected based on time. In order to do this, the medical record must reflect the total time spent with the patient, the time spent counseling and a description of the counseling/coordination of care activities 6. TEACHING PHYSICIAN NOTE: Only the teaching physician s time can be used to bill for time based services. It is important that only the teaching physician be able to enter time into the medical record when a resident is involved. B. Authorship An EMR must allow various individuals to make entries in the record. This not only includes ancillary personnel who may document preliminary information such as demographics, past/family/social history, review of systems, and vitals, but also corrections to the medical record. As is the requirement in the paper record, each entry must be authenticated to include the author and their credentials. The author of the documentation must be retained and displayed in electronic and printed forms. Systems with only a single authorization for a visit note may create compliance risks if there is no ability within the system to identify who the author is of each entry. This is especially true when the service is a shared visit involving care provided by both a non-physician provider (PA, NP, etc.) and a physician, or in conjunction with a resident. In its report to DHHS, RTI International recommends the use of date/time/user stamp identification for each entry and that this information is retained when data is entered into the medical record on behalf of the provider 7. For example, the record should be able to distinguish between information obtained and entered by staff as opposed to information entered into the record by staff on behalf of a provider. Authorship Recommendation of System Compliance Office and 1997 DG; 7 Recommended Requirements for Enhancing Data Quality in Electronic Health Record Systems, May 2007 at (Requirements and 4.2.6) Page 7

11 The EMR system should have some means of identifying the author and date of each entry into the patient s medical record. The EMR system should have a back-end audit trail to verify who entered each item into the medical record, including the date of such entry. The provider under whose name the services will be billed (billing provider) must authenticate/complete the medical record before it is billed to the payer. Dignity Health policy titled Documentation requires the provider to complete documentation as soon as possible - not longer than 72 hours after the visit. Additionally, no codes for claims processing should be submitted until the record is complete and supports the claim. Some Medicaid payers are data mining for services submitted prior to record authentication. These claims are then denied as false claims. C. Corrections/Amendments and Audit Trails Amendments and changes to the medical record must be accurately reflected and traceable to avoid improper alteration of the medical record. Such corrections must be dated, timed, and authenticated. After the encounter has been authenticated by the provider, there should be a mechanism to amend and/or change the record that can be easily audited to prevent fraudulent, untraceable, alteration of the record. RTI International, standard states that entries after the signature event should be retained as the original document and any changes/additions to the record thereafter must be handled as amendments that can be tracked through the system 8. This audit function of the EMR system should always be activated in order to identify legitimate changes from improper changes. The audit trail should include the identity of the user as well as the date and time of the amendment/change. Corrections/Amendments Recommendation of System Compliance Office All entries into the EMR should include the author s credentials, electronic signature as well as a date and time. All entries into the EMR should be auditable by provider (i.e., author) as well as by date and time of entry. Once the record has been authenticated by the provider, corrections/amendments must be separately entered and noted in the EMR, with the identity of the author as well as the date and time of the corrected/amended entry. There should never be the ability to erase or otherwise obliterate information in the EMR system that has been authenticated. 8 Recommended Requirements for Enhancing Data Quality in Electronic Health Record Systems, May 2007 at Page 8

12 V. ADDITIONAL RESOURCES A. AHIMA e-him Workgroup: Guidelines for EMR Documentation to Prevent Fraud Journal of AHIMA 78, no. 1 (January 2007). Name=bok1_ B. Tips for Preventing Most Common Evaluation and Management (E/M) Service Coding Errors, by Trailblazer Health Enterprises, LLC, August most%20common%20e-m%20coding%20errors.pdf C. Medical Necessity for Evaluation and Management Services, by Trailblazer Health Enterprises, LLC, August D. Recommended Requirements for Enhancing Data Quality in Electronic Health Records, Final Report, June 2007 prepared by RTI International for the Department of Health and Human Services. E. Foundation of Research and Education. Report on the Use of Health Information Technology to Enhance and Expand Health Care Anti-Fraud Activities (September 30, 2005) ONC Health Care Anti-Fraud Project Task Order HHSP EC ftp://ftp.ihs.gov/pubs/emr/him+bo/emr%20fraud%20article% pdf F. Hammond, et al. Are Electronic Medical Records Trustworthy? Observations on Copying, Pasting and Duplication AMIA 2003 Symposium Proceeding. (2003): G. Hirschtick, Robert F. Copy-and-Paste JAMA Vol. 295, no. 20 (May 23/31, 2006): Page 9

13 APPENDIX A - s Electronic Medical Record Macros Only TEACHING PHYSICIAN MACRO TITLE E/M: with Resident TEACHING PHYSICIAN MACRO STATEMENT I was present with the Resident during the history and exam. I discussed the case with the Resident and agree with the findings and plan as documented in the note except for my comments if noted below. ACCESS RIGHTS E/M: and Resident Perform Separately E/M: Primary Care Exception ( ; ; IPPE) I saw and evaluated the patient. I reviewed the Resident's note and agree with the findings and plan as documented in the note except for my comments if noted below. I have discussed the patient's care with the Resident. I have reviewed the patient's history and Resident's findings on exam, the patient's diagnosis/differential diagnosis and treatment plan. I concur with the treatment plan as documented by the Resident, except for my comments if noted below. Minor Procedure (< 5 min) I was physically present for the entire procedure. Present for Entire Single Surgery (Includes Endoscopic Surgery) Present for the Key/Critical Portions of Single Surgery/Endoscopic Surgery and Immediately Available 2 Surgeries - Key/critical portions DO NOT overlap (Each Case) Time Based Codes (Individual Medical Psychotherapy, Counseling/Coordination of Care, Critical Care, Discharge, etc) Psychiatric Services (Excluding individual medical psychotherapy) Anesthesia: One-on-one with Resident I was physically present for the entire surgery. I was physically present for the key/critical portions of this surgery and immediately available throughout the rest of this procedure. I was physically present for the key/critical portions of this case which were: [insert key/critical portions]. Dr. [ ] was immediately available at all other times during this procedure. I was personally present for [ ] minutes for this service. I was physically present during the psychiatric service or concurrently observed the psychiatric service by use of a one-way mirror or video equipment. [Time] I was physically present during all key/critical portions of this procedure. Page 10

14 TEACHING PHYSICIAN MACRO TITLE Anesthesia: Two Concurrent Cases Involving Residents (For each Case) Interpretation of Diagnostic Tests (Other than Pathology) Interpretation of Pathology Tests Endoscopic Diagnostic Procedures (Not Surgeries) TEACHING PHYSICIAN MACRO STATEMENT I was physically present with the Resident through the pre and post anesthesia care of this case and all other key/critical portions of the procedure which represented [Time]. I personally reviewed the image and the Resident's interpretation and agree with the findings except if noted below: I personally reviewed the slide and the Resident's interpretation and agree with the findings except if noted below: I was personally present during the entire viewing, including insertion and removal of the endoscope. ACCESS RIGHTS Page 11